Failure to Follow Physician Orders for Nephrostomy Tube Care
Penalty
Summary
A deficiency was identified when a resident with a percutaneous nephrostomy tube (PCN) did not receive care in accordance with physician's orders and professional standards of practice. Record review showed that the resident, admitted with an artificial opening of the urinary tract, had specific physician's orders for nephrostomy drain management, including emptying and recording output every shift, flushing the PCN with normal saline every day and evening shift, and performing PCN site care every two days. Documentation failed to show that these orders were consistently followed, with multiple instances where drain output was not recorded, the PCN was not flushed, and site care was not completed as ordered on specified dates and shifts. During an interview, the Director of Nursing Services confirmed that it was her expectation for the resident's PCN orders to be completed as prescribed. The findings were based on both record review and staff interview, and were initiated following a community complaint regarding concerns with facility staffing and medication errors.