Failure to Maintain Physician Orders and Catheter Equipment
Penalty
Summary
The facility failed to ensure that appropriate physician orders were obtained for a resident with a supra-pubic catheter and did not maintain catheter irrigation equipment. The resident, who was admitted with a neurogenic bladder, paraplegia, and depression, had a supra-pubic catheter in place. However, the clinical records lacked physician orders for the care and management of the catheter, including its irrigation. During an observation, the resident was found in bed with a drainage bag containing thick urine with sediment, and an irrigation syringe kit was present but dated several days prior. Interviews with the Unit Manager RN and the Director of Nursing confirmed the absence of current physician orders for the catheter and irrigation, indicating a lapse in maintaining proper medical directives and equipment for the resident's catheter care.
Plan Of Correction
1. Physician orders were obtained for irrigation of suprapubic catheter for R367. Plan of care was updated to reflect irrigation orders. 2. Director of nursing or designee will conduct a house audit of residents with suprapubic catheters to ensure orders for irrigation are present and reflected in the plan of care. 3. Director of nursing or designee will in-service licensed nurses on ensuring physician orders for irrigation of suprapubic catheters are obtained on admission and reflected in the plan of care. 4. Director of nursing or designee will audit 2 residents with suprapubic catheters weekly for 3 weeks to ensure physician orders and care plan are present. Audit findings will be shared with QAPI committee.