Failure to Maintain Complete Clinical Record and EBP Order for Catheterized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with accepted professional standards and practices for one resident who required Enhanced Barrier Precautions (EBP). The resident was an older male with dementia, bladder-neck obstruction, urinary incontinence, and a cognitive communication deficit, and he had an indwelling/foley catheter. His quarterly MDS showed a BIMS score of 9, indicating moderately impaired cognition. Review of his quarterly care plan dated 12/26/25 did not include that he required EBP due to his indwelling/foley catheter, and review of his electronic medical record revealed there was no provider order for EBP, despite facility protocol requiring such an order when a resident is under EBP. During observation, the resident’s room displayed EBP signage on the door, with gloves and gowns available outside the room and a trash can inside near the exit, and the resident was in bed with an indwelling/foley catheter and a privacy cover on the drainage bag. In interviews, the RN/MDS nurse confirmed that the resident had an indwelling/foley catheter that required him to be under EBP and acknowledged that an order was required but not present in the record. The DON stated that the facility’s protocol required an order for EBP so staff would know what precautions to take during high-contact care and confirmed there was no facility policy related to physician’s orders. This lack of an EBP order and omission from the care plan constituted incomplete and inaccurate clinical documentation for the resident.
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