Failure to Obtain Physician Order and Review Hospital Records Prior to Catheter Removal
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of urinary retention was admitted to the facility with an indwelling urinary catheter, as documented in hospital discharge records and transition of care forms. The resident's hospital records specified that the catheter was to remain in place, with follow-up care by a urologist recommended. Despite these instructions, the Assistant Director of Nursing (ADON) removed the resident's urinary catheter without obtaining a physician's order or thoroughly reviewing the hospital discharge documents. The physician order sheets did not contain any order to discontinue the catheter, and there was no documentation that the resident's physician was notified of the catheter removal. The Director of Nursing (DON) later acknowledged that the hospital documents indicating the need for the catheter were missed and that a physician's order should have been obtained prior to removal. The facility also failed to document the resident's urinary retention diagnosis from the transition of care forms and did not provide requested facility policies during the survey. These actions and omissions resulted in the facility not providing care and services according to accepted professional standards of practice for one resident reviewed for improper nursing care.