Lack of Current Physician Order for Indwelling Catheter
Penalty
Summary
A resident with a diagnosis of neurogenic bladder had an indwelling urinary catheter in place. The physician initially ordered the discontinuation of the Foley catheter, but the resident refused, stating that the physician had not discussed the change and requested to speak with the physician first. The physician later agreed to allow the resident to keep the catheter and instructed that it be changed monthly. However, a review of the resident's medical record revealed there was no current physician's order for the catheter, including details such as catheter size or the frequency of changes, despite the resident continuing to have the catheter in place and performing their own catheter care. Observations confirmed the presence of the indwelling catheter and drainage bag, and staff interviews indicated awareness of the lack of a current physician's order for the catheter or its care. The absence of an updated physician's order for the ongoing use and maintenance of the urinary catheter constituted a deficiency in providing appropriate catheter care and ensuring proper documentation as required for residents with indwelling catheters.