Failure to Obtain Physician Orders and Provide Catheter Care
Penalty
Summary
The facility failed to notify the physician of a newly admitted resident's indwelling urinary catheter and did not obtain a physician's order for the care and maintenance of the catheter. Upon admission, the resident's Minimum Data Set (MDS) did not indicate the presence of a catheter, and a review of the resident's records revealed no documentation or orders related to catheter care. Staff interviews confirmed that no orders had been entered and that the resident was incorrectly designated as independent for catheter care, with no evidence of catheter care being provided. The resident reported that staff typically only emptied the catheter bag when it was full, and there was no documentation to show that appropriate catheter care was performed to prevent catheter-associated urinary tract infections (CAUTIs). The lack of physician notification, absence of care orders, and failure to provide documented catheter care were confirmed by the LPN, Unit Manager, and Director of Nursing during interviews.