Failure to Ensure Timely and Complete Urinary Catheter Orders and Care
Penalty
Summary
The facility failed to ensure that appropriate urinary catheter care was provided in accordance with standards of care for one resident who was admitted with an indwelling urinary catheter due to obstructive uropathy and other urological diagnoses. Upon admission, documentation confirmed the presence of a Foley catheter, but there was no corresponding physician order for the catheter, including details such as catheter size, balloon size, or the medical diagnosis necessitating its use. The treatment administration record did not reflect an order for catheter care until more than two weeks after admission, and the care plan referenced catheter care and monitoring for infection, but lacked supporting physician orders during this period. Interviews with nursing staff and the DON revealed that the facility's process required batch orders for residents with indwelling catheters, specifying catheter details and the reason for use. However, these orders were not entered at the time of admission, and staff acknowledged that without such orders, there was no way to verify if catheter care was being completed as required. The facility was unable to provide a policy regarding catheter care, and the deficiency was identified through record review and staff interviews.