Lack of Physician Orders and Documentation for Foley Catheter
Penalty
Summary
The facility failed to ensure that proper physician orders were in place for a resident with a Foley catheter. Upon review, it was found that the resident, who had multiple diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and quadriplegia, did not have a documented physician order specifying the diagnosis, Foley or balloon size, or instructions for catheter changes. The care plan referenced catheter use and related interventions, but the physician orders lacked essential details such as the reason for the catheter and specific directions for its management. Additionally, there was no documentation of recent catheter changes, despite the DON stating that a change had occurred about two weeks prior. The facility's own policy requires that residents with indwelling catheters receive appropriate care, including maintaining dignity and privacy, but the lack of clear physician orders and documentation did not meet these standards. The DON confirmed the absence of necessary orders and documentation, and acknowledged that not all residents with neuromuscular bladder dysfunction require a catheter, further highlighting the need for individualized and documented medical justification.