Failure to Provide and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to follow physician orders for providing urinary catheter care every shift for residents with indwelling catheters, as well as failed to obtain and document a diagnosis in the physician's orders for an indwelling catheter. For one resident with a chronic indwelling catheter, there were multiple documented instances across several months where catheter care was not recorded as provided on various shifts. This resident had a history of urinary tract infections, including infections with multidrug-resistant organisms, and received antibiotic treatments as a result. The treatment administration record showed numerous days and shifts with missing documentation of catheter care, despite an active physician order for care every shift. Another resident was admitted with a Foley catheter in place, but there were no physician orders documented regarding catheter care, catheter size, or catheter changes. Facility staff confirmed that such orders should have been present but were unable to locate them. Facility policies require that all medications and treatments, including catheter care, be ordered by a physician and implemented by staff, but these requirements were not met for the residents reviewed.