Failure to Transcribe Catheter Orders and Implement Enhanced Barrier Precautions
Penalty
Summary
Two residents did not receive appropriate care and services to prevent urinary tract infections (UTIs) due to failures in transcribing and implementing physician orders related to Foley catheter management. One resident, who was admitted with a chronic Foley catheter and a history of UTI, had hospital discharge instructions for monthly catheter changes and as-needed irrigation. These orders were not transcribed into the medical record or onto the Medication Administration Record (MAR) or Treatment Administration Record (TAR), as required by facility policy. The Director of Nursing confirmed that the order should have been transcribed and implemented, but it was not, and the physician was not notified for alternative orders. Another resident with a Foley catheter and a urology clinic order for monthly and as-needed catheter changes also did not have the order transcribed onto the MAR or TAR. This resident reported that the catheter had not been changed as ordered. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for this resident, who had an indwelling medical device, as required by facility policy. There was no EBP signage or personal protective equipment (PPE) available near the resident’s room, and staff initially indicated EBP was not needed, despite policy stating otherwise.