Failure to Follow Physician Orders for Catheterization and Specialist Follow-Up
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate care for one resident with complex medical needs, including cerebral palsy, seizures, urine retention, obstructive and reflux uropathy, and acute kidney failure. Upon admission, there was no documentation that required follow-up appointments with a urologist and nephrologist were scheduled, despite clear instructions in the hospital discharge summary. Additionally, the facility did not have policies addressing intermittent catheterization or appointment scheduling, and the resident's medical record lacked evidence of assessment for urinary retention or the need for straight catheterization as ordered. Physician orders for urinary catheterization, including specific catheter size, frequency of change, and as-needed straight catheterization, were not fully implemented or documented. After the resident pulled out the urinary catheter, there was no documentation of reinsertion as ordered, and staff interviews revealed a lack of awareness regarding the straight catheterization order. Monitoring of urine output was inconsistent, with staff only documenting bowel movements and not tracking the number of wet briefs or assessing bladder distention as expected. The facility's failure to follow physician orders and ensure complete documentation led to the identified deficiency.