Failure to Ensure Proper Catheter Orders and Documentation
Penalty
Summary
Surveyor observations, record reviews, and staff interviews revealed that the facility failed to provide appropriate treatment and services for residents with urinary catheters. For one resident with a foley catheter, there was no physician order on file specifying the catheter size, balloon size, or diagnosis to support its use, despite facility policy requiring this documentation. Both the LPN and the Director of Nursing Services (DNS) confirmed the absence of the required order. Similarly, another resident with a suprapubic catheter did not have an order specifying the catheter size, balloon size, or diagnosis, as required by policy, which was also acknowledged by the DNS. Additionally, a third resident with a foley catheter had a physician order for a trial void following a urologist's recommendation, but there was no evidence in the records that the trial void was attempted or failed as ordered. The DNS was unable to provide documentation to show that the trial void had been carried out. These findings indicate lapses in following facility policy and physician orders regarding catheter care and documentation.