F0684

D

Incomplete and Inaccurate Documentation of Foley Catheter Orders and Monitoring

Bradenton, Florida Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate documentation of physician orders and related care for a resident with an indwelling Foley catheter. The resident had a history of hemiplegia and hemiparesis following cerebral infarction, personal history of UTIs, neurogenic bladder, and an indwelling Foley catheter. Physician orders and the care plan included catheter care as ordered, monitoring for signs and symptoms of UTI, and a specific order to change the Foley catheter on the 15th of every month and as needed. Review of the January MAR showed an order to change the Foley catheter on the 15th, but the MAR entry for that date was blank, and there was no progress note documenting that the catheter was changed or explaining why it was not changed on that date. A progress note on 1/29/26 documented that the Foley catheter was changed, but did not provide a rationale for changing it on that day instead of the ordered date.

In February, the MAR showed that the catheter was changed on 2/12/26 by one LPN and again on 2/15/26 by another LPN, despite the monthly order specifying the 15th and as-needed changes. There was no documentation in the progress notes explaining the rationale for changing the catheter on 2/12/26 or for changing it again on 2/15/26. Interviews with both LPNs confirmed they recalled changing the catheter but could not recall the reasons for the changes. The DON confirmed that the catheter was changed on both dates based on the MAR and stated that if a nurse did not receive information in nurse-to-nurse report, they might not have known it had already been changed, indicating a lack of clear documentation and communication regarding catheter changes.

Additional documentation issues were identified with behavior monitoring and urine output orders. Behavior monitoring entries in February were mostly marked “No,” with no corresponding progress notes describing what behaviors, if any, were observed, despite the order requiring documentation of specific behaviors when present. For March, the order to “EMPTY FOLEY BAG RECORD OUTPUT every shift” was documented incorrectly with a “y” on several dates instead of recording the urine output in cubic centimeters, and one shift was left blank while another was marked “NA,” with no progress notes documenting the output on those dates. The DON acknowledged that the “y” entries were incorrect, that “NA” should not have been used, and that there was no documentation of urine output in the MAR, TAR, or progress notes as required by the physician order.