Lack of Physician Order Specifications for Indwelling Catheter
Penalty
Summary
The facility failed to obtain and document physician order specifications for the size and balloon inflation amount of an indwelling Foley catheter for one resident. The resident in question had diagnoses including obstructive uropathy, hypertension, and heart failure, and was noted to use an indwelling Foley catheter as per the Minimum Data Set assessment. While physician orders were present for catheter care, securing the catheter, and applying a drainage bag, there were no documented orders specifying the catheter size or the amount of balloon inflation required. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the clinical record lacked the necessary specifications for the indwelling catheter. The absence of these details was found during a review of the resident's clinical record and physician orders, which did not include the required information for one of three residents reviewed for catheter care.