Failure to Obtain Physician Order and Monitor Indwelling Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling urinary catheter for one resident who was admitted from a hospital with the catheter in place. Upon review, there was no physician's order for the urinary catheter documented in the resident's records, including the physician order recap report, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the relevant months. Additionally, there was no documentation of monitoring or care for the urinary catheter, no order for when to change the catheter, and no order for a catheter securement device. The care plan did note catheter care, but this was not supported by corresponding physician orders or nursing documentation. The resident in question had multiple medical diagnoses, including atrial fibrillation, heart failure, renal insufficiency, wound infection, respiratory failure, cellulitis, and lymphedema. Despite these complex conditions and the presence of an indwelling catheter upon admission, the facility did not ensure that a physician's order was obtained or that appropriate monitoring and documentation of catheter care occurred. The Director of Nursing confirmed that a physician's order was required for the catheter and its discontinuation, and that monitoring should have been documented by nursing staff.