Lack of Documented Clinical Indication for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter had a documented clinical indication for use for one resident. The resident was admitted in August 2025 with diagnoses including schizophrenia, and the admission evaluation dated 8/8/25 indicated the resident had an indwelling urinary catheter in place. However, the admission orders did not include any order for a urinary catheter, and review of the clinical record revealed no documented evidence supporting a clinical indication for the catheter’s use. On 3/16/26 at 9:16 AM, an LPN/Resident Care Manager confirmed that the resident had been admitted with an indwelling urinary catheter and that there was no indication documented for its use. This deficiency was cited under the requirement to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including appropriate catheter care and care to prevent urinary tract infections, and it was noted that this failure placed residents at risk for infection.
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