Failure to Ensure Physician Orders and Monitoring for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with an indwelling urinary catheter by not ensuring there were physician orders for catheter care and monitoring. The resident, who had a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, was admitted with an indwelling urinary catheter and was at risk for urinary tract infection (UTI) as documented in the care plan. Despite this, there were no documented physician orders for catheter care after the resident returned from a general acute care hospital, and the treatment administration records did not show evidence that catheter care was provided or monitored as required. Observations and interviews revealed that nursing staff observed abnormal urine characteristics, including dark yellow, blood-tinged, and cloudy urine with hematuria, but did not report these findings to the attending physician. Both LVNs involved stated that the urine appearance was considered the resident's baseline and therefore did not notify the physician, even though the care plan and facility policy required prompt reporting of such findings. Additionally, one LVN performed a urinary catheter irrigation without a physician order, and another provided catheter care and changed the drainage bag without proper documentation or orders. The facility's Director of Nursing confirmed that there were no urinary catheter care orders in place prior to the observed change in the resident's condition and that the resident's catheter was not being monitored as required. Laboratory results later confirmed the presence of infection, with elevated white blood cell count and bacteria in the urine. Facility policies reviewed indicated that catheter care, monitoring, and documentation were required, and that changes in condition should be promptly reported to the physician, but these procedures were not followed in this case.