Failure to Follow Physician Orders for Indwelling Catheter Care
Penalty
Summary
The facility failed to follow physician orders regarding the care and management of an indwelling urinary catheter for a resident with obstructive uropathy. Physician orders specified that a 24 French coude foley catheter was to be changed monthly and as needed for blockage or obstruction, and that only a registered nurse (RN) was permitted to perform the catheter change. However, documentation revealed that a licensed practical nurse (LPN) changed the resident's coude catheter on one occasion, contrary to the physician's order. Additionally, the resident's catheter was changed by an RN on a date that did not align with the monthly schedule, and there was no documented evidence of a complication, such as blockage or obstruction, that would have warranted an earlier change. The clinical record also showed inconsistencies in documentation regarding who performed the catheter changes and when they occurred. The Director of Nursing (DON) performed a scheduled monthly catheter change, but previous changes were not consistently documented as being performed by an RN as required. The Nursing Home Administrator confirmed these findings during an interview. The facility did not ensure that the resident's indwelling urinary catheter was managed according to physician orders, both in terms of the appropriate licensed staff performing the procedure and adherence to the prescribed schedule.