Failure to Ensure Proper Indwelling Catheter Management and Physician Orders
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter for one resident. Upon admission, the resident, who had a minimally displaced sacral fracture and was cognitively intact, was observed with a urinary catheter and collection bag. However, there were no physician orders in place for the indwelling catheter at the time of admission, and the care plan referenced catheter care without corresponding medical orders. The resident reported not knowing why she had a catheter and stated that her urine bag was not emptied for the first few days, suggesting a lack of awareness and attention from staff regarding her catheter care needs. Interviews with nursing staff and management revealed that the process for verifying and entering admission orders was not followed, resulting in the absence of required physician orders for the catheter. Staff members acknowledged that orders should have been in place and that nurse managers were responsible for verifying their accuracy. The facility's policy required evaluation and documentation of medical necessity for indwelling catheters upon admission, as well as corresponding physician orders, but these steps were not completed for this resident until several days after admission.