Failure to Transcribe and Implement Monthly Catheter Change Order
Penalty
Summary
The facility failed to follow a urology provider's order to change the indwelling urinary catheter monthly for a resident with obstructive and reflux uropathy and neuromuscular dysfunction of the bladder. The resident had a history of urinary catheter use and was admitted to the facility with several physician orders related to catheter care, including cleansing every shift, monitoring output, changing the catheter when occluded or leaking, and anchoring the tubing. However, after a urology appointment, a new order was documented in the provider's progress note instructing the facility to change the catheter monthly. This order was not transcribed into the resident's active physician orders, nor was it scheduled on the Medication Administration Record or Treatment Administration Record for the appropriate month. Nurse interviews revealed that the nurse responsible for the resident on the day of the urology appointment did not notice or transcribe the monthly catheter change order, describing it as an oversight. The process for transcribing new orders from specialist appointments relied on the assigned nurse, and at the time, there was no unit manager to review and ensure the completeness and accuracy of transcribed orders. The Director of Nursing confirmed that all new orders from specialist appointments should be transcribed correctly and accurately, but this did not occur in this instance.