Failure to Obtain Catheter Size Order and Perform Scheduled Catheter Change
Penalty
Summary
The facility failed to obtain a physician's order specifying the size of a urinary catheter and did not change the catheter as ordered for a resident with obstructive uropathy and an indwelling urinary catheter. Staff interviews revealed that when the catheter was changed, there was no order for the catheter size, and the nurse was instructed to use the same size as the one being removed. Both the Unit Manager and Medical Director confirmed that an order specifying the catheter size should have been present, and the interim DON stated that the nurse should have obtained such an order if it was missing. Additionally, the facility did not ensure that the resident's urinary catheter was changed according to the physician's order. The Medication Administration Record indicated that the catheter change was scheduled, but it was initialed by a Medication Aide, who stated that changing catheters was outside her scope of practice. Nurses on duty during the scheduled change were unaware of the order and did not perform the catheter change. The Unit Manager confirmed that it was the nurse's responsibility to review the MAR and complete scheduled tasks, and the Medical Director expected catheter changes to be performed as ordered.