Failure to Follow Physician Orders for Suprapubic Catheter Changes
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for the timely changing of a suprapubic catheter for a resident with a history of stroke and obstructive reflux uropathy. The resident was admitted and readmitted to the facility with orders from a urologist to have the suprapubic catheter changed monthly or as needed for clinical indications. However, review of the medical record showed that the monthly catheter change order was not documented or carried out in May, and the order was not properly entered into the treatment administration record. Staff interviews revealed that nurses were unaware of a standing monthly catheter change order and believed the resident either went to the urologist for changes or that the order was only as needed. The physician confirmed that the order should have included both monthly and as-needed changes, and the DON acknowledged that the order had been entered as PRN only, without clarification from the urologist. The administrator and DON both stated that unclear orders should be clarified by nursing staff, but this was not done. As a result, the resident did not receive a scheduled suprapubic catheter change in May, contrary to the urologist's and hospital discharge orders.