Failure to Transcribe Physician Order for Indwelling Urinary Catheter
Penalty
Summary
A deficiency occurred when staff failed to transcribe a physician's verbal order for an indwelling urinary catheter into the electronic medical record for one resident. The facility's policy requires that indwelling urinary catheters be used only when clinically necessary and that all such use be in accordance with physician orders, including documentation of the diagnosis, catheter size, and frequency of change. Despite this, review of the resident's order summary report showed no order for the catheter, even though a progress note documented a verbal order and the catheter was placed. Observations on two separate days confirmed the resident had an indwelling urinary catheter in place. The resident, who was admitted with diagnoses including urinary tract infection and congestive heart failure, reported the catheter was used to monitor urinary output due to fluid retention and heart failure. During interviews, an LPN confirmed that although a verbal order was received, it was not transcribed into the physician's orders, and the DON stated that staff are expected to document and transcribe such orders directly into the electronic health record.