Failure to Obtain Physician Order and Provide Catheter Care
Penalty
Summary
The facility failed to obtain a physician's order for catheter care and did not provide or document catheter care for a resident with an indwelling urinary catheter. Policy review indicated that catheter care should be performed to prevent complications such as urinary tract infections, and that care should be documented with the date, time, and name of the caregiver. Medical record review showed that after the resident returned from hospitalization for altered mental status and a urinary tract infection, there were no active physician orders for catheter care, and no documentation of catheter care for six days following readmission. Interviews confirmed these deficiencies: the resident reported that catheter care was not consistently performed, and an LPN was unable to provide an order for catheter care, acknowledging that such an order should exist. The DON also confirmed that an order for catheter care should be in place and that care should be documented daily. The lack of both a physician's order and documentation of catheter care for the resident constituted the deficiency.