Failure to Obtain Physician Order for Indwelling Urinary Catheter
Penalty
Summary
A deficiency occurred when the facility failed to obtain a physician order for the use and care of an indwelling urinary catheter for a resident who was readmitted with a history of neuromuscular dysfunction of the bladder and a spinal fracture. The resident had an indwelling urinary catheter in place during a recent hospital stay and at the time of discharge, and the care plan included interventions for catheter management. However, upon review of the facility's records, there was no physician order for the indwelling urinary catheter or its care after readmission. Interviews with nursing staff revealed confusion and miscommunication regarding responsibility for reactivating or entering the necessary orders for the catheter. One nurse believed the oncoming nurse would reactivate the orders, while the other nurse thought it was the first nurse's responsibility. Both the Medical Director and the DON confirmed that a physician order was required for the catheter, and the omission was acknowledged as an oversight during the facility's clinical morning meeting. The administrator also confirmed that nursing was responsible for ensuring physician orders were in place for catheter care.