Failure to Document Pain Medication Timely and to Secure Foley Catheter per Care Plan
Penalty
Summary
The facility failed to meet professional standards of quality for one resident by not ensuring timely documentation of pain assessment and medication administration, and by not following the resident’s catheter care plan. The resident had severe cognitive impairment, lacked decision-making capacity, and was dependent for ADLs, with diagnoses including metabolic encephalopathy, muscle weakness, and ESRD. On one observed date, an LVN stated she had administered Tylenol 325 mg for the resident’s 2/10 pain but did not document the administration, assessment, or reassessment in the MAR right away because she had to attend to another resident. The facility’s own Medication Administration policy required the person administering the medication to record the administration on the MAR after the medication pass and to review the MAR at the end of each pass to ensure doses were administered and documented. Another LVN acknowledged that late documentation of medication administration could result in another dose being given. The facility also failed to follow the resident’s care plan related to an episode of blood in the urine. During an observation, the resident was noted to have an indwelling Foley catheter without a StatLock or other securement device in place. Review of the resident’s care plan titled “Resident with an episode of blood in the urine” showed an intervention to secure the catheter to facilitate urine flow and prevent kinking and accidental removal. An LVN confirmed that the facility did not follow the resident’s care plan or the standard of care when the catheter was not secured. The DON stated that the resident was at risk for penile trauma due to long-term Foley catheter use and needed a StatLock to prevent trauma and skin irritation. The facility’s Indwelling Urinary Catheter policy indicated that residents with indwelling catheters receive catheter care daily and PRN, and that staff may secure the tubing with a securement device PRN to prevent migration, friction, or tension of the catheter.
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