Failure to Change Indwelling Catheter per Physician Orders
Penalty
Summary
Staff failed to follow physician orders to change an indwelling catheter monthly for a resident with a history of obstructive uropathy, recent urinary tract infection, and cerebral infarction. The resident required substantial to maximal assistance with toileting and transfers and had an indwelling catheter in place following a recent hospitalization. Physician orders and the treatment administration record directed that the catheter and drainage bag be changed monthly, but documentation showed the catheter was last changed on 5/19/25, with no evidence of a change during the month of June as required. Staff interviews confirmed that the indwelling catheter was not changed according to the schedule, and the treatment record was not updated to reflect when the next change was due. The charge nurse did not perform the scheduled change, resulting in the catheter being missed for the month. The facility's policy required appropriate catheter care to prevent infection and maintain resident comfort and dignity, but this was not followed in this instance.