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Based on record review and interview, the facility failed to require documentation of patients' responses to having urinary catheters discontinued. Five (#1, 3, 8, 9, and 11) of 11 patients had urinary catheters discontinued with no documentation of the time removed and patient response to the procedure.

Findings include:

Review of charts of 11 patients who underwent coronary artery bypass graft (CABG) surgery revealed all had urinary catheters placed before surgery. All 11 patients had the urinary catheter discontinued before hospital discharge, as all were documented to be urinating without a catheter at the time of discharge. Five (#1, 3, 8, 9, and 11) of the 11 patients had no documentation of the time the catheter was removed and no documentation of the response to the procedure (complications, pain, bleeding, etc.).

Staff #7 reviewed the charts and confirmed the lack of documentation.