Failure to Obtain Orders and Maintain Catheter Care for Two Residents
Penalty
Summary
The facility failed to obtain and implement appropriate physician orders for catheter care and did not properly maintain urinary catheters for two residents. One resident with a history of paraplegia and neuromuscular bladder dysfunction had a suprapubic catheter since September, but there were no consistent orders or documentation for required catheter flushes or monitoring of urinary output for several months. The resident reported having to remind staff to flush the catheter and experienced multiple emergency department visits due to catheter blockages, with medical records confirming repeated complications and lack of regular flushing. Staff interviews and documentation review revealed that supplies for the catheter were not consistently available, and central supply staff were unaware of the resident's needs or the frequency of required catheter changes. Another resident with a Foley catheter did not have any physician orders or care plan documentation related to the catheter, despite progress notes indicating its presence and a diagnosis of urinary tract infection. The resident reported infrequent emptying of the catheter bag and uncertainty about whether staff were providing regular catheter care. An LPN initially stated that catheter care was performed and documented, but upon review, could not find evidence of this in the treatment administration record. The DON confirmed that catheter orders should include specific details and be entered by the admitting nurse, but acknowledged that no such orders were in place for this resident. Facility policies required catheter care to be performed each shift and in accordance with physician orders, specifying the type, size, and frequency of catheter changes. However, the review found that these policies were not followed, as evidenced by missing orders, lack of documentation, and inconsistent care practices. Both residents experienced lapses in catheter maintenance, with one resident suffering repeated complications and hospital visits due to inadequate care.