Failure to Enter and Provide Routine Indwelling Catheter Care
Penalty
Summary
The facility failed to enter and implement physician orders for indwelling catheter care for a resident who was admitted with an indwelling Foley catheter. The resident, who had diagnoses including a lumbar vertebra fracture, type 2 diabetes mellitus, bacteremia, and overactive bladder, was admitted with a Foley catheter in place. Although there were orders for changing the catheter as needed and for irrigation in case of blockage, there was no order entered for routine catheter care every shift and as needed. Review of the Certified Nursing Assistant (CNA) documentation also showed no evidence that catheter care was performed during the resident's stay. Interviews with nursing staff revealed that the admitting nurse and others involved in entering orders did not ensure that the required catheter care order was entered into the system. The Director of Nursing and Administrator confirmed that the resident did not have orders for routine Foley catheter care and was not receiving the appropriate care for the indwelling catheter as required by facility policy. The deficiency was identified through record review and staff interviews, which confirmed the lack of both orders and documentation of catheter care for the resident.