Failure to Obtain and Document Orders for Self-Catheterization
Penalty
Summary
The facility failed to ensure proper catheter use and care in accordance with standards of practice for a resident who performed self-catheterization. The facility's policies required a physician's order specifying the procedure, catheter size, frequency, and monitoring, as well as documentation of catheter care and any related observations or issues. However, record review revealed that there were no documented physician orders for the resident's self-catheterization, nor was there evidence of staff monitoring or documentation of the procedure in the resident's medical record or treatment administration record. The resident involved had a history of paraplegia, neuromuscular dysfunction of the bladder, and was dependent for transfers. Upon admission, the resident was incontinent of bowel and bladder and had been self-catheterizing prior to admission. Nursing notes indicated that the resident continued to self-catheterize to assist with bladder control, but there was inconsistency in documentation regarding the presence of a catheter, participation in a toileting program, and monitoring of urinary output or complications. Staff provided the resident with catheters when supplies were low, but did not document the specifics of the catheterization process or any monitoring. Interviews with nursing staff, the ADON, DON, and the Administrator revealed uncertainty about the need for physician orders and staff monitoring for self-catheterization. While some staff believed monitoring was necessary, others were unsure of the requirements. Leadership acknowledged that an order specifying catheter size, frequency, and responsibility for monitoring should have been present, and that the care plan should have included this information. Despite these expectations, the required orders and documentation were not in place during the resident's stay.