Failure to Follow Physician Orders and Securement Protocols for Indwelling Catheters
Penalty
Summary
The facility failed to provide appropriate treatment and services related to indwelling urinary catheters for three residents. For two residents with chronic medical conditions requiring Foley catheters, staff did not follow physician orders regarding the correct catheter size. In both cases, the residents had 16 French (Fr) catheters in place, while the physician orders specified 18 Fr catheters. This discrepancy was confirmed by both the unit manager and nursing staff during direct observation and review of the residents' records and orders. Additionally, another resident with a history of urinary retention and an indwelling catheter did not have a securement device in place as required by physician orders and facility policy. During multiple observations, no securement device was found securing the catheter tubing, and the resident reported never having had such a device. The unit manager acknowledged the absence of the securement device and indicated awareness of the issue during the survey. The facility's own policy requires adherence to physician orders for catheter size and the use of securement devices to prevent complications. The failure to follow these orders and policies was directly observed and confirmed through interviews and record reviews, resulting in deficiencies in catheter care for the affected residents.