Failure to Ensure Timely Catheter Care Orders for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling catheters had appropriate physician orders for catheter care during specific periods. For one resident, there were no catheter care orders from the time of admission until over a month later, despite the resident being admitted with a Foley catheter in place. The resident's care plan eventually included interventions for catheter care, but this was not reflected in the physician orders or the medication administration record (MAR) during the initial period. Documentation showed that catheter care was provided only after the appropriate orders were entered, and prior to that, there was no documentation of catheter care orders in the MAR. Another resident was admitted with a Foley catheter and was incontinent of bowel and bladder, but did not have catheter care orders for several days following admission. The care plan for this resident included interventions related to the presence of an indwelling medical device, but the physician orders for catheter care were not entered until several days after admission. Documentation of catheter care and monitoring only began after the orders were in place. Interviews with staff revealed that catheter care was generally provided as part of routine care and that CNAs and nurses were aware of the need for such care, even if it was not triggered in the resident's plan of care. However, the absence of formal physician orders for catheter care was acknowledged by nursing and administrative staff, who indicated that orders should have been entered upon admission. The lack of timely catheter care orders was identified during order reviews and audits, and staff recognized that this omission could result in inadequate monitoring and care for residents with catheters.