Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain a physician's order for a resident to perform independent urinary self-catheterization and did not conduct or document an assessment to ensure the resident could safely and sanitarily perform this procedure. Observations revealed that the resident was using a straight catheter kit, and interviews with the DON confirmed that there was no physician order or documentation of an assessment or progress note regarding the resident's ability to self-catheterize. Review of the resident's medical record from the relevant period showed no evidence of a nursing assessment for safe and sanitary self-catheterization, nor any physician authorization for the practice. The resident in question was admitted with a history of being unable to void and was noted to be able to self-catheterize, but also had some urine leakage and required supervision for toileting due to unsteadiness. The care plan indicated a need for self-catheter use and included interventions for assistance and monitoring for UTI symptoms, but did not address the lack of a physician order or assessment for self-catheterization. Facility guidelines for self-intermittent catheterization emphasized safety, comfort, and adherence to protocols, but these were not followed in this case.