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Based on medical record review, policies, and interviews, the nursing staff failed to document nursing notes necessary to monitor a patient's condition when Foley catheter care and assessments were not documented every shift.

Review of the "Nurse Directed Protocol for the Removal of Indwelling Catheters" revealed that each day a catheter is in place, the date and criteria for keeping the catheter would be documented. If the patient was being seen by a urologist, the urologist would determine when the catheter could be removed. If a physician ordered the catheter, the physician would document daily the criteria for keeping the catheter. Catheters would be changed within 72 hours prior to obtaining a urine culture.

Review of the "Personal Care and Hygiene" policy #GC.24, revised 11/21, revealed that personal care guidelines included Foley Catheter care. The policy revealed that nurse aides could assist with personal care, but the Registered Nurse was accountable for oversight of personal care needs. Refusal of personal care would be documented in the medical record. Foley catheter care was to be completed daily or per shift. Foleys were to be emptied and documented in the intake/output section of the medical record per shift and as needed. Each shift, the nursing staff would inspect the Foley catheter, the color of the urine, and if there were any signs/symptoms of infection. The nurse would communicate with the physician how long the catheter had been in place and obtain orders to remove the catheter unless contraindicated.

Medical record review revealed that a Foley Catheter was inserted on 11/13/21 at 7:30 a.m. because of urinary retention. Review of a Hospitalist Progress Note by MD AA on 11/25/21 at 2:18 p.m. revealed that P#1 continued to require a Foley catheter because P#1 was bedbound in acute critical illness. Review of a Nursing Assessment by RN CC on 11/25/21 at 7:30 p.m., revealed that the Foley had been re-inserted on 11/24/21 at 6:00 p.m. The urine was clear, yellow to amber. Review of the Hospitalist Progress Note by MD AA on 11/27/21 at 11:04 a.m. revealed that a urinalysis on 11/27/21 at 12:35 a.m. was abnormal with cloudy urine, there was a large amount of blood and protein in the urine, and a small number of leukocytes, red blood cells, and white blood cells. Results were suggestive of contamination from an outside source and a culture recollection was recommended if clinically indicated. Review of a Nursing Assessment on 11/28/21 at 8:00 a.m. revealed that a new Foley was placed on 11/28/21 for a urine culture. The urine was clear. There was scrotal/penile edema and scant urine noted. Review of the nursing Flowsheets, Personal Care sections, from 11/15/21 at 2:40 a.m. to 11/27/21 at 9:00 a.m. revealed that Catheter Care/Peri care were completed on the following dates/times:

11/15/21, 2:40 a.m.
11/19/21, 2:00 a.m.
11/21/21, 1:25 p.m.
11/24/21, 9:28 a.m.
11/25/21, 1:03 p.m.
11/25/21, 9:43 p.m.

Review of the nurses and physicians progress notes failed to reveal daily criteria for keeping the Foley catheter in place.
During a telephone interview with the complainant on 12/28/21 at 9:45 a.m., the complaint said P#1's penis was swollen, and pus was coming out around the Foley. The complainant said the nurse told the complainant the pus was normal. The complainant said the Foley had not been cleaned in a week or more, and there was Klebsiella (bacteria) in the urine, blood, and lungs.

During an interview with the Medical Doctor (MD) AA on 12/29/21 at 1:03 p.m. in the Conference Room, MD AA said that any catheter may cause an infection. A Foley catheter may cause a bladder infection, and a patient can get septic. MD AA said the facility would try to take out Foleys as soon as possible, but anytime P#1 was touched or turned, he would become unstable with blood pressure and heartrate. P#1 was not a candidate to get rid of the catheter at that point. MD AA said P#1 was going into kidney failure, meaning the urine coming out was going through diseased kidneys and not producing normal looking urine. On 11/28/21, the urinalysis was negative for nitrates, which the presence of nitrates usually indicates a urinary tract infection (UTI). The results of the urinalysis were suggestive of contamination. MD AA said that when urine is collected from a catheter that has not been in place for two days, the urine will look like it has infection when it does not. Bandemia in the WBC was an indication of something infectious going on in P#1. On 11/28/21, blood and urine cultures were being rechecked.

During a telephone interview with RN CC, on 12/29/21 at 2:00 p.m., RN CC said she did not recall drainage from the Foley. RN CC said the Foley would be cleaned once a shift during the bath and would be documented on the flowsheets under peri care and catheter care. RN CC said she does not always chart catheter care, but the nurses and technicians would work together to keep patients clean.

During an interview with RN DD on 12/29/21 at 2:51 p.m. in the Conference Room, RN DD said that P#1 had edema "all over," and P#1's penis was swollen. RN DD said there was no drainage or signs of infection around the Foley catheter. Foley catheter care was done every shift, so RN DD said she would have seen if the area had been infected.

During an interview with the Chief Clinical Officer (CCO) KK on 12/30/21 at 10:00 a.m. in the Conference Room, CCO KK acknowledged that the nursing staff were not documenting each time peri-care and catheter care were completed.