Failure to Obtain Timely Physician Order for External Catheter Use
Summary
The facility failed to ensure that a physician's order was obtained for a resident's immediate care upon admission. This deficiency was identified for a resident who was readmitted to the facility and was using an external urinary catheter at bedtime. Despite the resident's preference and use of the catheter, a physician's order was not obtained until several days after the readmission. The resident had diagnoses including a right femur fracture, osteoporosis, and malnutrition, and was assessed to have intact cognition. The resident's care plan indicated the use of an external catheter at night, but the necessary physician's order was missing until it was obtained on a later date. Interviews with facility staff revealed a lack of clarity in the facility's policy regarding the roles of Certified Nursing Assistants and Licensed Nurses in the use of external urinary catheters. The Director of Nursing Services acknowledged that a physician's order should have been obtained upon the resident's admission. The attending physician was not informed of the resident's use of the external catheter until several days after the readmission, highlighting a communication gap in the facility's admission process. The deficiency was noted during a recertification survey, indicating a failure in the facility's protocol for obtaining timely physician orders for resident care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions and an indwelling Foley catheter did not have physician orders in place for the catheter at admission. Medical records, nursing notes, and the care plan lacked documentation of the catheter order, although CNA documentation confirmed care was provided and surveyors observed the catheter in use. The DON confirmed the absence of physician orders, and the facility lacked a related policy.
A resident with critical illness myopathy and moderate cognitive impairment was readmitted from the hospital without physician notification or medication and treatment orders in place. Staff, including an LPN, confirmed they lacked the necessary orders to provide proper care, and both the medical director and nurse practitioner were not informed of the readmission. The DON acknowledged the orders were not transcribed as required.
A resident with a surgical incision was admitted without proper orders for incision care, leading to a delay in treatment. The hospital recommended washing the incision twice daily, but the facility did not initiate this care until several days later. The ADON confirmed the oversight in obtaining necessary orders upon admission.
Lack of Physician Orders for Indwelling Foley Catheter
Penalty
Summary
The facility failed to ensure that physician orders were in place for a resident with an indwelling Foley catheter at the time of admission. The resident, who was admitted with multiple diagnoses including atrial fibrillation, congestive heart failure, liver cirrhosis, diabetes mellitus type 2, and chronic kidney disease with dialysis, was cognitively intact and required significant assistance with activities of daily living. Medical record review showed no physician orders for the Foley catheter, and there was no documentation in the nursing progress notes or plan of care regarding the catheter. Certified Nursing Assistant documentation confirmed care was provided for the catheter, and observations during the survey verified the presence of the indwelling Foley catheter. The Director of Nursing confirmed the absence of physician orders, and the facility did not have a policy related to physician orders for indwelling Foley catheters.
Failure to Notify Physician and Obtain Orders on Resident Readmission
Penalty
Summary
Licensed nursing staff failed to notify the physician of a resident's readmission and did not obtain medication or treatment orders to guide care for the resident upon return from the hospital. The resident, who had a diagnosis of critical illness myopathy and moderate cognitive impairment, was readmitted to the facility, but there was no evidence in the medical record that physician orders for medications or treatments were in place on the date of readmission. Staff interviews confirmed that the LPN working on the unit at the time did not have any orders to properly care for the resident and did not notify the provider of the resident's return. Further interviews revealed that both the medical director and nurse practitioner were not informed of the resident's readmission, and the director of nursing acknowledged that there was no reason for the failure to transcribe or enter the necessary orders. The administrator stated that it was expected for all orders to be entered and the provider notified immediately upon admission or readmission, but this did not occur in this instance.
Failure to Obtain Admission Orders for Surgical Incision Care
Penalty
Summary
The facility failed to ensure that admission orders were obtained for a resident with a surgical incision, which led to a deficiency in providing appropriate care and treatment. Resident #178, who was admitted with a surgical incision on the neck, did not have any orders in place to wash the incision as recommended by the hospital from which they were discharged. The hospital record indicated that the incision should be washed twice daily with soap and water, but this was not initiated until several days after the resident's admission. Upon observation, it was noted that the resident had clear tape covering the incision, and the resident reported that no treatments had been performed on it by the facility. The physician orders for the month did not include any instructions for incision care until an order was finally placed to wash the incision every shift. The Assistant Director of Nursing confirmed that there should have been an order in place upon admission to cleanse the surgical incision, which was not done, resulting in a lapse in care.
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