Failure to Implement Physician Orders for Catheter Care
Penalty
Summary
The facility failed to implement physician orders for the care of an indwelling urinary catheter for one resident. Record review showed that the resident was admitted with multiple diagnoses, including chronic obstructive pulmonary disorder, tracheostomy, obstructive sleep apnea, and muscle wasting. The resident was cognitively intact and required assistance with self-care activities. The care plan identified the resident as being at risk for urinary tract infection, but there were no physician orders in place for catheter care, cleansing, or flushing as of the date reviewed. Interviews with facility staff confirmed that catheter care is conducted according to physician orders in the system of record. However, both an LPN and the DON acknowledged that no such orders had been entered for this resident, despite the presence of an indwelling urinary catheter. The facility's policy on urinary catheter care emphasizes the importance of routine hygiene and regular emptying of the drainage bag to prevent catheter-associated urinary tract infections. The lack of physician orders for catheter care represented a failure to follow established procedures and contributed to the cited deficiency.