Failure to Obtain Physician Orders for Indwelling Urinary Catheter Management
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician orders for the management of an indwelling urinary catheter for a resident who was readmitted with obstructive and reflux uropathy. The resident was readmitted with an indwelling urinary catheter, as documented in the nursing admission tool and provider progress notes. Despite this, a review of the electronic medical record revealed that no physician orders regarding the care or management of the indwelling urinary catheter were entered from the time of readmission until several months later. The care plan created upon readmission included interventions for catheter care, such as maintaining the catheter anchor, observing for signs of infection, and providing catheter care each shift. However, these interventions were not supported by corresponding physician orders in the resident's record. Staff interviews confirmed that catheter care was provided as part of routine practice, but also revealed that staff were unaware of the absence of required physician orders and did not notify supervisors about the missing orders. The Director of Nursing confirmed that no catheter care or changing orders were found for the resident prior to the later date, and the Administrator acknowledged that nursing staff did not follow up on the missing orders from the hospital discharge summary. The deficiency was attributed to the failure of the admitting nurse to enter the necessary orders and the assumption by staff that catheter care would be completed regardless of the presence of orders.