Failure to Obtain Physician Order for Intermittent Catheterization at Admission
Penalty
Summary
The facility failed to obtain a physician's order for intermittent self-catheterization upon admission for a resident with a diagnosis of flaccid neuropathic bladder and a thoracic vertebra fracture. Despite information from the resident's daughter that the resident had been performing intermittent catheterization at home, there was no physician order documented in the medical record at the time of admission. Multiple staff interviews confirmed that the resident was performing intermittent catheterization several times per shift without a physician's order in place. Record reviews, including the Minimum Data Set (MDS), indicated the resident had impaired cognition and required intermittent catheterization. Facility policy requires a physician's order for all treatments, including catheterization, to guide care and prevent complications. Both nursing staff and the Assistant Director of Nursing acknowledged the importance of having such orders documented to ensure proper care planning and resident safety, but this was not done for the resident in question.