Failure to Obtain Timely Physician Order for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to reassess the continued need for an indwelling urinary catheter and did not obtain a physician's order for its use for one resident upon admission from the intensive care unit. The resident, who had a history of pneumonia, acute respiratory failure with hypoxemia, and acute kidney injury, was admitted to the facility with a urinary catheter in place. The discharge summary from the hospital did not indicate a need to continue the catheter, and there was no physician order for the device upon admission. Documentation in the resident's care assessments and nursing notes confirmed that the urinary catheter remained in use for two days following admission without a physician order specifying the medical necessity for the device. Nursing staff documented the presence and management of the catheter, but no order was present until two days after admission. The Director of Nursing confirmed that the catheter was used without a physician order and acknowledged that staff should have clarified the need for the device or removed it if there was no indication to continue its use. The facility's policy required daily assessment of the need for an indwelling catheter, prompt removal if criteria were not met or if there was no provider order, and provider contact if there was uncertainty. These procedures were not followed, resulting in the resident having an indwelling urinary catheter for two days without documented medical necessity or a physician order.