Incomplete Medical Record and Missing Physician Orders for Catheter Management
Penalty
Summary
A deficiency occurred when the facility failed to maintain a complete and accurate medical record for a resident with a history of urinary retention, neuromuscular bladder dysfunction, and an indwelling catheter. After an unwitnessed fall, the resident was found to have pulled out their Foley catheter. Despite a standing physician order not to replace the catheter if it was pulled out, the charge nurse reinserted a new catheter without a documented physician order authorizing this action. RN #1 acknowledged that an order should have been written after consulting with the APRN, but this was not done, and no explanation was provided for the omission. Additionally, when the resident's catheter was again found to be out, a new physician order was obtained to reinsert the catheter if the resident did not void, but the order did not specify the length of time staff should wait before reinsertion. Nursing staff and facility leadership recognized that such orders typically include a specific time frame, but the order in this instance lacked that detail. The facility was unable to provide a policy regarding physician orders, and interviews did not clarify why the required time frame was omitted from the order.