Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
A resident with multiple complex medical conditions, including malignant neoplasm of the prostate, Stage IV pressure ulcer, multiple myeloma not in remission, paraplegia, and a colostomy, was admitted to the facility from a hospital with an indwelling Foley catheter in place. Review of the resident's admission orders and all subsequent orders up to several months after admission revealed there was no physician's order for the continued use of the indwelling urinary catheter. Facility policy for indwelling urinary catheters required verification of orders, but this step was not followed. Nursing progress notes documented the presence and replacement of the Foley catheter, and staff interviews confirmed the ongoing use of the catheter without a physician's order.