Lack of Physician Order for Indwelling Catheter and Catheter Care
Penalty
Summary
A resident with a diagnosis of benign prostatic hyperplasia was admitted and later readmitted to the facility with an indwelling urinary catheter. The resident's care plan documented the presence of the catheter and included interventions to monitor for discomfort, leaking, and obstruction. However, a review of the physician orders revealed there were no current orders for the urinary catheter or for catheter care. Staff provided catheter care without verifying the existence of an active physician order, and no documentation of catheter care was made on the Treatment Administration Record due to the absence of such an order. During interviews, staff acknowledged that they did not check for a current order before providing care and that clarification should have been sought upon the resident's readmission.