Failure to Obtain Physician Order for Urinary Catheter
Penalty
Summary
A deficiency was identified when the facility failed to obtain appropriate physician orders for a urinary catheter for one resident. The facility's policy requires that any resident admitted with an indwelling catheter, or who subsequently receives one, must be assessed for removal unless clinically necessary, and that proper physician orders must be obtained. Review of the resident's admission and care plan records indicated the presence of a catheter, but there was no corresponding physician order for its use after admission. The only order on file was from the hospital prior to admission. During observation, the resident was found with a catheter in use, and staff interviews confirmed that there was no specific physician order for the catheter in the facility's records. The Assistant Director of Nursing acknowledged that the required physician order had not been obtained as mandated by facility policy and state regulations. The resident had a medical history including diabetes, hyperlipidemia, and chronic kidney disease, and was being monitored for incontinence at the time of the deficiency.