Failure to Obtain Physician Orders for Indwelling Catheter and Catheter Care
Penalty
Summary
The facility failed to ensure that two residents with indwelling catheters had physician orders for the catheter and for catheter care upon admission. One resident was admitted with a Foley catheter in place following a hospital stay, and although the care plan noted the presence of the catheter and interventions for care, there were no corresponding physician orders for the catheter or for catheter care documented in the medical record from admission through several days after. The Treatment Administration Record also showed no evidence of scheduled or completed catheter care during this period. The lack of orders was confirmed by both a registered nurse and the Director of Nursing during record review and interviews. Similarly, another resident admitted with an indwelling catheter had care plans indicating the need for catheter care and monitoring for infection, but there were no physician orders for the catheter or for catheter care documented until several days after admission. The Treatment Administration Record did not show evidence of catheter care being performed prior to the late entry of the physician order. Both the registered nurse and the Director of Nursing confirmed the absence of required orders for catheter care during this time frame. Facility policy required daily and as-needed catheter care for residents with indwelling catheters, and that all treatment orders be transcribed into the electronic treatment administration record.