Failure to Provide Physician-Ordered Catheter Care and Timely Catheter Changes
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters as ordered by physicians. For one resident with a cervical spinal cord injury and neurogenic bladder, the physician's order required monthly catheter changes and catheter care every shift. However, the resident reported that the catheter had not been changed since admission, and the responsible nurse acknowledged missing the order due to it being combined with another order. The care plan and medical record confirmed the need for regular catheter changes and care, but these were not performed as prescribed. Another resident with acute kidney failure and neurogenic bladder had a physician's order for catheter care every shift and as needed. The resident stated that staff did not clean the catheter every shift, and two CNAs confirmed that catheter care had not been performed for this resident during their shifts. The facility's policy emphasized the importance of catheter care to prevent complications, but staff interviews and resident statements indicated that care was not provided according to orders.