Failure to Provide Physician-Ordered External Urinary Catheter System
Penalty
Summary
The facility failed to provide an external urinary catheter system for a resident with a physician order for its use. The resident, who had diagnoses including chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, and dementia, was frequently incontinent of bladder and always incontinent of bowel, and required substantial assistance for transfers and toileting. Despite a physician order for an external urinary catheter to be applied nightly, the resident's care plan did not include this intervention, and the system was not implemented during the resident's stay. Documentation showed that the resident and her representative had requested the external catheter, and a urology consult recommended its use to reduce skin breakdown and infection. However, facility staff, including the DON and Administrator, stated that the external catheter system was not allowed, citing facility policy, although no such policy was documented or provided to the resident or her representative. Interviews with the resident confirmed that she had previously used an external urinary catheter at home and would have preferred to continue its use in the facility, but agreed to regular check and change care only because the external catheter was not permitted. The facility's admission agreement and information packet did not inform residents that external urinary catheters were not allowed. The lack of implementation of the physician-ordered external urinary catheter system, absence of related interventions in the care plan, and lack of clear facility policy or communication regarding the prohibition of the device led to the deficiency.