Failure to Provide Ordered Straight Catheterization for Resident with Neurogenic Bladder
Penalty
Summary
A cognitively intact resident with end stage kidney failure and a diagnosis of neurogenic bladder was admitted to the facility and required straight catheterization three times daily, as ordered by a physician. The resident also received dialysis three times per week. The care plan and physician's orders specified the need for straight catheterization every shift, regardless of the resident's dialysis schedule. Review of the medication and treatment administration records for July and August revealed multiple instances where the resident did not receive straight catheterization as ordered, particularly on days when the resident was scheduled for dialysis, despite not leaving for dialysis until later in the morning. Additional documentation indicated missed catheterizations on other dates and shifts, with reasons such as the resident not being available or the procedure being completed on a previous shift. The DON confirmed that there was no documented evidence that the straight catheterization was completed as ordered on the identified dates and shifts.