Failure to Provide Physician-Ordered Catheter Flushes Due to Documentation Error
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a neurogenic bladder, requiring an indwelling urinary catheter, did not receive physician-ordered catheter flushes for a period of ten consecutive days. The physician had ordered the catheter to be flushed twice daily, but this order was not properly documented in the electronic medical record system. Specifically, the order was entered as 'other orders (no documentation required),' which prevented it from appearing on the treatment administration record used by floor nurses to guide daily care. As a result of this documentation error, nursing staff were unaware of the flush order and did not perform or record the prescribed catheter flushes. Multiple interviews with nursing staff and facility leadership confirmed that the order was not visible to those responsible for the resident's care, and there was no evidence in the medical record that the flushes had been administered during the specified period. The issue was identified during a review of the resident's care and confirmed through interviews and record reviews. The resident involved had a history of neuromuscular dysfunction of the bladder, urinary tract infection, and Parkinson's disease, and was admitted for long-term care due to neurogenic bladder. The failure to provide the ordered catheter flushes was not detected during daily interdisciplinary team meetings, as the review process did not identify the improperly documented order. The facility's own Charting and Documentation policy requires that all procedures and treatments be documented in detail, but this was not followed in this instance.