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Based on interview and record review, the hospital failed to ensure the Registered Nurse (RN) supervised the care of each patient as evidenced by failure to ensure catheter care was being performed and documented on 2 (Pt. #3 and Pt. #5) of the 2 (Pt. #3 and Pt. #5) sampled patients who had urinary catheters.
Findings:

Review of the policy and procedure titled, "Indwelling Urinary Catheter (Foley) Care and Management" read, in part, clean the periurethral area carefully to prevent catheter movement and urethral traction. Inspect the periurethral area for signs of inflammation and infection, make sure that the catheter is secured properly and assess the securement device daily.

Review of the Registered Nurse's (RN) job description revealed, in part, the RN is responsible for utilizing the nursing process while delivering, directing and supervising care to patients admitted to the nursing unit and maintains complete and accurate records of all activities performed.

Review of the Certified Nursing Assistant's (CNA) job description revealed patient care in collaboration with licensed staff, organizes patient care and general unit activities to accomplish required functions, priorities, workload, answers call light promptly, and completes assignments in a timely manner. Provides designated patient care to assigned patients under the direct supervision of a licensed nurse.

Patient #3
Review of Patient #3's medical record revealed, in part, an admit date of 12/27/2022. Patient #3 remained inpatient with a primary chief complaint of worsening pressure ulceration to the sacrum. Further review of the medical record revealed on 12/27/2022 a Physician's order for a gravity drainage Foley catheter.

Review of the Activities of Daily Living (ADL) indwelling catheter care electronic record revealed there was no documentation of catheter care being provided for 2 (12/30/2022 and 12/31/2022) of the 17 days Patient #3 has been hospitalized.

In interview on 01/12/2022 at 9:28 a.m. S1DQM verified catheter care should be documented in the electronic record, the RN should ensure the care was provided and there was no documentation of catheter care being provided on dates of service, 12/30/2022 and 12/31/2022.

Patient #5
Review of Patient #5's medical record revealed, in part, an original admit date of 07/28/2022 with a diagnosis of Pyoderma Gangrenosum and a physician's order for Foley catheter insertion. On 08/09/2022, Patient #5 was transferred to an acute care facility for a change in condition and was re-admitted on 08/11/2022. Patient #5 was discharged on 08/19/2022.

Review of the ADL indwelling catheter care electronic record revealed there was no documentation of catheter care being provided for 3 (08/15/2022, 08/16/2022 and 08/15/2022) of the 9 days Patient #5 was hospitalized.

In interview on 01/12/2023 at 9:42 a.m. S1DQM verified catheter care should be documented in the electronic record, the RN should ensure the care was provided and there was no documentation of catheter care being provided on dates of services 08/15/2022, 08/16/2022 and 08/19/2022.