Failure to Follow Physician Orders for Catheter Care and 1:1 Supervision
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician's orders for urinary catheter care and for required 1:1 staff supervision. For one resident with chronic kidney disease, urinary tract infection, prostatic hyperplasia, urinary urgency, and urinary retention, a Foley catheter was placed at a urology appointment. However, there was no physician order for the urinary Foley catheter documented in the resident's clinical record since the date of placement, despite the presence of a hard copy urology consultation indicating the catheter. The facility's policy required specific documentation for catheter care, but the necessary physician order was missing. Additionally, the same resident had a physician order for 1:1 supervision every shift for safety, but this was not consistently implemented. During an observation, the resident was found in their room without 1:1 staff present, and the assigned nurse aide confirmed she had stepped away from the resident's room for approximately five minutes. Interviews with facility leadership confirmed the lack of a physician order for the Foley catheter and the lapse in required supervision.