Failure to Maintain Catheter Orders and Timely Incontinence Care
Penalty
Summary
Facility staff failed to ensure that a treatment order was in place for a resident with a suprapubic catheter following the resident's return from a hospital stay. The resident was discharged to the hospital and returned with a suprapubic catheter, as noted in the hospital discharge summary, which recommended the catheter be changed in one month. However, upon readmission, no physician orders were entered for the catheter, and the previous order to change the catheter every 28 days had been discontinued. The Director of Nursing confirmed that it was the responsibility of the admitting nurse to ensure all necessary orders were entered at the time of admission, but acknowledged that no current orders for the catheter were present in the resident's medical record. Additionally, staff failed to provide timely incontinence care for another resident, who reported being left unchanged for extended periods following episodes of incontinence. Review of the resident's bladder continence Kardex revealed multiple instances where the resident was not changed for several hours after an incontinent episode, with specific dates identified where care was delayed. The Director of Nursing stated that incontinence care should be provided every two hours and before shift changes, but acknowledged that on the dates reviewed, the resident was not changed in a timely manner.