Failure to Transcribe Catheter Care Orders Upon Resident Re-Admission
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder and returned from the hospital with an indwelling catheter had appropriate physician orders in place for catheter care upon re-admission. Record review showed that when the resident was re-admitted, there were no orders transcribed for the catheter, including instructions for catheter care, when to change or flush the catheter, or what to assess. The resident had a diagnosis of urinary retention and severe cognitive impairment, and was observed with a catheter in place, but the necessary orders to guide ongoing care were missing from the medical record. Interviews with the DON, ADON, and RN involved in the admission confirmed that the admitting nurse did not place the required catheter orders, despite the resident returning with a catheter from the hospital. The facility's policy requires that all treatments, including catheter care, be administered only upon a physician's order, and that such orders be recorded immediately in the resident's chart. The lack of orders for the catheter upon re-admission resulted in a failure to ensure continuity of care for the resident.