Failure to Obtain Physician Order and Use Catheter Securement Device
Penalty
Summary
A resident with chronic urinary retention was admitted to the facility with an indwelling urinary catheter. The resident's baseline care plan indicated the presence of the catheter, and the Minimum Data Set confirmed its use. However, a review of the resident's physician orders revealed there was no documented order for the indwelling urinary catheter, although there was an order for catheter care and output documentation. During an observation of catheter care, it was noted that the resident did not have a catheter securement device in place, although there was no visible tension on the tubing and the drainage bag was appropriately positioned. Multiple nursing assistants and a nurse interviewed were unaware of the absence of the securement device until it was pointed out, and all acknowledged that a securement device should have been used. The DON and Administrator confirmed that both the lack of a physician order and the missing securement device were oversights by staff.