Care Village At Mattapan

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record, when nursing failed to document a urinary catheter change.Findings include:The Facility Policy, titled, Charting and Documentation, undated, indicated observations, medications administered, services performed, etc., would be documented in the residents' clinical records.Resident #1 was admitted to the Facility in May 2023, diagnoses included Cauda Equina Syndrome (injury or herniated disk compresses nerve roots at the bottom of your spinal cord.

The cauda equina nerves communicate with your legs and bladder. It causes back pain, weakness and incontinence) and neuromuscular dysfunction of the bladder.Review of Resident #1's August and September 2025 active Physician's Orders, indicated he/she had a physician's order, dated as effective since 05/19/23, which indicated nursing staff may change his/her indwelling urinary catheter as needed for blockage.Further review of Resident #1's August and September 2025 active Physician's Orders indicated he/she had a second Physician's Order, dated as effective since 05/19/23, which indicated nursing staff may change his/her indwelling urinary catheter as needed for blockage or dislodgement every eight hours as needed.Review of Resident #1's Hospital History and Physical (H&P), dated 09/13/25, indicated he/she was transferred from the Facility to the Hospital Emergency Department with symptoms of a urinary tract infection.

The Hospital H&P indicated his/her indwelling urinary catheter was last changed at the Facility two and a half to three months earlier.

Review of the Facility's internal investigation, dated 09/25/25, indicated the Facility discovered through their investigation process that Nurse #1 had changed Resident #1's indwelling urinary catheter on 08/16/25, but had not documented the catheter change anywhere.Review of Resident #1's Treatment Administration Record (TAR) for August 2025 indicated nursing did not check off that his/her indwelling urinary catheter was changed on any days that month.Review of Resident #1's medical record indicated there was no documentation to support that nursing changed his/her indwelling urinary catheter on 08/16/25.During a telephone interview on 10/15/25 at 02:26 P.M., Nurse #1 said that on 08/16/25 she had changed Resident #1's Foley catheter at his/her request due to discomfort and blockage.

Nurse #1 said she did not document the procedure anywhere in Resident #1's medical record but should have.

During an interview on 10/15/25 at 09:45 A.M., the Director of Nurses (DON) said Nurse #1 should have documented Resident #1's indwelling urinary catheter change on 08/16/25, and said nursing should document care related to indwelling urinary catheters daily but had not.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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