HospitalInspections.org

Based on review of facility policies and procedures, review of medical records (MR) and interviews with staff (EMP), it was determined that the facility failed to adequately assess and develop an appropriate plan of care to address bladder function and urinary needs for one patient with a history of an indwelling urinary catheter for one of seven medical records reviewed (MR1).

Findings include:

Review of facility policy titled "Indwelling Urinary Catheter Necessity" and dated February 2012, revealed that; "Patients admitted to a Kindred healthcare facility with an existing indwelling urinary catheter will be assessed by a licensed RN to determine the need for the indwelling urinary catheter within 48 hours of admission utilizing the criteria presented in this policy." Further review of policy revealed that "Upon discontinuation of the indwelling catheter, the licensed nurse will document, "Discontinuation per Assessment Criteria", patient tolerance and findings in the medical record."

Review of facilty policy titled "Assessment/Re-assessment - Interdisciplinary Patient and dated August 2013, revealed that; "The RN admission assessment of the patient will include: Biophysical, Psychosocial, Cognitive Environmental, Self-Care Needs Assessment, Wound Risk Assessment, Pain, Fall Risk, Educational Needs Assessment, Communication, Age and Development, Social and Cultural and Spiritual and Discharge Planning."

Review of MR1 revealed no documented evidence that an assessment was performed to determine the necessity for / or discontinuation of an indwelling urinary catheter as required by facility policy. Further review of MR1 revealed no documented evidence that a plan of care was developed to address this patient's bladder function and urinary needs.

Interview on March 25, 2014 at 11:00 AM, with EMP3 confirmed that the medical record did not contain documentation that an assessment was performed to determine the necessity of maintaining or discontinuing the indwelling urinary catheter.