Failure to Document and Maintain Physician Orders for Indwelling Urinary Catheter
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including Parkinson's disease, diabetes, and systemic lupus erythematosus, did not receive appropriate treatment and services related to the management of an indwelling urinary catheter. The facility failed to ensure that a physician's order for the indwelling urinary catheter, which had been in place for 95 days, was entered into the electronic physician orders. Additionally, there was no documentation of when catheter care was provided or if the catheter had been replaced every 30 days as ordered by hospice services. Record reviews revealed that although the resident's care plan addressed the risk of infection related to the indwelling catheter, the electronic clinical record lacked an active order for the catheter. The medication administration records (MAR/TAR) for several months showed no documentation of catheter care or catheter replacement. Nursing notes indicated that the catheter was replaced on at least two occasions by hospice nurses, but these actions were not consistently documented in the resident's clinical record. Interviews with nursing staff confirmed that catheter care was performed and that the hospice nurse was responsible for changing the catheter, but staff were unclear about documentation requirements and acknowledged the absence of a physician's order in the electronic record. The facility's policy required assessment, documentation, and monitoring of catheter use and care, but these procedures were not followed. The Director of Nursing and the Administrator both acknowledged that the lack of a physician's order and failure to document catheter care could result in missed care and inadequate monitoring. Observations confirmed the presence of the indwelling catheter, and interviews with staff and the resident's private sitter corroborated that catheter care was being provided, albeit without proper documentation.