Failure to Change Indwelling Urinary Catheter per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with chronic kidney disease, benign lipomatous neoplasm of the kidney, and neuromuscular dysfunction of the bladder did not have their indwelling urinary catheter changed according to physician orders. The resident's care plan and physician orders specified that the catheter should be changed once monthly and as needed for infection prevention. However, review of the Treatment Administration Records (TAR) for three consecutive months showed no documentation that the catheter was changed during this period. The last documented catheter change was on 3/28/25, and both the resident and multiple nursing staff confirmed that no catheter change had occurred in the subsequent two months. Interviews with the Medical Doctor, Director of Nursing, and other nursing staff confirmed that the expectation was for the catheter to be changed every thirty days as ordered. Despite this, none of the nurses interviewed recalled changing the catheter for the resident during the required timeframe, and the Director of Nursing was unable to identify any staff who had performed the change. The deficiency was identified when the catheter was finally changed on 6/16/25, more than two months after the previous change, and the physician was notified that this was the first change in over two months.