Failure to Document Foley Catheter Necessity and Care Plan Leading to UTI
Penalty
Summary
The deficiency involves the facility’s failure to document clinical findings supporting the need for an indwelling Foley catheter (IFC) and to initiate a care plan addressing its use for one resident. The resident was admitted with right-sided weakness and paralysis following a cerebral infarction and was documented on a Minimum Data Set as always incontinent of bladder without an indwelling catheter. Subsequent physician orders entered by an LVN initiated IFC care and catheter orders first for urinary retention and later for neurogenic bladder, but these orders were later discontinued and then re-entered for neurogenic bladder. The resident’s care plan did not contain any care plan addressing IFC use, and there was no documented evidence in the medical record of urinary retention, neurogenic bladder, or other clinical findings demonstrating the necessity for the IFC. The resident was later transferred to a general acute care hospital with an IFC in place and was found to have lethargy, yellow urine with sediment draining from the catheter, and a urinalysis showing signs of infection; he was admitted for altered mental status secondary to a urinary tract infection. A CNA reported that the resident had an IFC “for a while” and did not know why it was in place. The LVN who entered the catheter orders stated that residents may need an IFC for urinary retention or a diagnosis requiring it, but he could not recall why this resident needed an IFC and acknowledged there was no documentation to support the need. The DON confirmed there was no care plan for the IFC and stated that a change in urinary status should have prompted a change-of-condition assessment, physician and family notification, and initiation of a care plan. The facility’s own policy required documentation of clinical or medical conditions demonstrating the need for an indwelling catheter and inclusion of catheter use in the plan of care, which was not done in this case.
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