Failure to Document Urine Characteristics and Foley Catheter Change per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for urinary catheter care and documentation for two residents with indwelling Foley catheters. One resident was admitted with multiple diagnoses including hypertension, hyperlipidemia, congestive heart failure, muscle weakness, difficulty in walking, chronic kidney disease, and obstructive and reflux uropathy, and had an MDS indicating minor memory problems and dependence on staff for ADLs, with an indwelling urinary catheter in place. Another resident was admitted with diagnoses including cerebral infarction, fractures of the left lower leg and left radius, acute respiratory failure with hypoxia, endocarditis, dysphagia, and atrial fibrillation, and also had an MDS indicating minor memory problems, total dependence on staff for ADLs and bed mobility, and an indwelling urinary catheter. Both residents had care plans for indwelling catheters related to obstructive uropathy that included interventions to monitor, record, and report signs and symptoms of UTI such as pain, burning, blood-tinged urine, cloudiness, deepening of urine color, and foul-smelling urine. Record review showed that for both residents, the Weekly Summary notes did not include required urine characteristics. For the first resident, Weekly Summary notes dated 2/28/26 and 3/14/26 had the urine color, consistency, odor, and clarity sections left blank. For the second resident, Weekly Summary notes dated 3/7/26 and 3/14/26 also had the urine color, consistency, odor, and clarity sections left blank. The MDS nurse stated that Weekly Summary notes are completed by licensed nurses and should be complete, including urine characteristics. In a concurrent interview and record review, the DON confirmed that the urine characteristics were not documented for these residents and stated that monitoring for urine would be at risk from this omission. The facility’s catheter care policy required documentation of the character of urine, including color, clarity, and odor, and the charting and documentation policy required that all services provided and any changes in the resident’s condition be documented in the medical record. A separate deficiency was identified for the same first resident regarding lack of documentation of a Foley catheter change. The resident’s records showed an indwelling urinary catheter and a care plan directing staff to monitor, record, and report signs and symptoms of UTI. During a telephone interview, an LVN reported that when she came on the 3 pm–11 pm shift on 3/3/26, she was informed that the treatment nurse had changed the resident’s Foley catheter and that she was to administer pain medication; she further stated that the nurse who changes the Foley should document it in the chart. During a concurrent interview and record review, the DON verified that there was no documentation in the progress notes for a Foley catheter change on that date and acknowledged that if the catheter was changed, the nurse should have documented it. The facility’s catheter care policy required documentation of the date and time catheter care was given, the name and title of the individual providing care, all assessment data obtained, any problems or complaints related to the procedure, and how the resident tolerated the procedure, and the charting and documentation policy required that all services provided be documented in the medical record.
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