Failure to Obtain Physician Orders and Document Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received care and services in accordance with professional standards. Specifically, the facility did not obtain physician's orders for the use and care of the resident's catheter, nor did it maintain documentation for catheter care and maintenance. The resident, who had multiple diagnoses including obstructive and reflux uropathy, sepsis, and a stage 2 pressure ulcer, was admitted and readmitted with an indwelling urinary catheter. The care plan indicated the need for catheter care every shift and monitoring for complications, but there was no consistent documentation of catheter care in the treatment administration record or progress notes for several days. Observations confirmed the presence of the catheter, and staff interviews revealed that while catheter care was reportedly performed, there was no supporting documentation in the electronic medical record to verify that care was consistently provided. The facility's own policy required timely assessments, documentation of clinical indications, and adherence to infection prevention protocols, but these were not followed as evidenced by the lack of physician orders and incomplete documentation.