Failure to Change Indwelling Urinary Catheter as Ordered
Penalty
Summary
A resident with a history of neurogenic bladder and a chronic indwelling urinary catheter was admitted to the facility with physician orders specifying that the catheter should be changed on a particular date. The order for the catheter change was transcribed into the resident's medical record by a nurse, but it was not entered into the Medication Administration Record (MAR) or Treatment Administration Record (TAR). As a result, the scheduled catheter change was not performed as ordered. Interviews with facility staff, including the nurse responsible for the admission and the Director of Nursing (DON), confirmed that the omission occurred because the order was not properly processed to appear on the MAR or TAR. The DON acknowledged that without the order on these records, nursing staff would not be aware of the need to change the catheter. The Nurse Practitioner (NP) and Administrator both stated that their expectation was for the catheter to be changed as ordered, but this did not occur during the resident's stay.