Lack of Physician Order for Urinary Catheter Change
Penalty
Summary
A deficiency occurred when the facility failed to ensure a physician's order was documented for the insertion of a size 20 French urinary catheter for a resident with a neurogenic bladder. The resident was admitted with an indwelling urinary catheter size 16 French, as documented in the hospital discharge records. On a subsequent date, the resident experienced new abdominal pain, bleeding, and severe spasms, prompting the attending physician to be notified and to order diagnostic tests and interventions, including flushing and irrigation of the urinary catheter. Despite these interventions, nursing progress notes indicated that the 16 French catheter was replaced with a size 20 French catheter. However, a review of the physician's orders did not reveal any documentation authorizing this change. The registered nurse who performed the catheter replacement stated that he believed he had communicated with the physician but confirmed there was no documented order for the procedure. The Director of Nursing also verified the absence of a physician's order for the catheter change.