Failure to Ensure Physician Orders and Privacy for Indwelling Catheters
Penalty
Summary
The facility failed to ensure proper treatment and services for residents with indwelling urinary catheters, as evidenced by the lack of a physician's order for one resident's catheter and the absence of privacy covers on catheter bags for three residents. Specifically, one resident did not have a physician's order for her indwelling urinary catheter, nor was there any indication of catheter care in her care plan, despite her medical record and MDS assessment indicating catheter use. The Director of Nursing confirmed that no orders or care plan documentation could be found for this resident's catheter. Additionally, observations revealed that three residents with indwelling catheters had their catheter bags uncovered while in and outside their rooms. One resident was seen wheeling down the hallway with her catheter bag visible and reported that a privacy cover was almost never used. Another resident's family member corroborated that the catheter bag was typically not covered during visits. A third resident was observed with an uncovered, nearly full catheter bag in her room. Staff interviews confirmed that privacy covers were available and intended to maintain resident dignity, but were not consistently used. The facility's policy required catheter drainage bags to be covered at all times.