Failure to Obtain Physician's Orders for Catheterization Procedures
Penalty
Summary
Nursing staff failed to follow physician's orders regarding the use of urinary catheters for a resident. The facility's policy requires that nursing staff review and obtain a physician's order prior to inserting an indwelling urinary catheter or performing a straight catheterization to obtain a urine sample. However, documentation revealed that an indwelling urinary catheter was inserted for urinary retention without evidence of a physician's order. Additionally, urine samples were obtained via straight catheterization on two separate occasions without documented physician's orders for these procedures. The resident involved was cognitively intact and required staff assistance for daily care needs, as indicated by a recent Minimum Data Set (MDS) assessment. The Director of Nursing confirmed that staff did not obtain the necessary physician's orders prior to performing these catheterization procedures, which is not in accordance with facility policy and regulatory requirements.