F0690

D

Failure to Obtain and Implement Orders for Indwelling Catheter Care and Monitoring

Fishers, Indiana Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document appropriate catheter care, monitoring, and urine output documentation for a resident with an indwelling urinary catheter. The resident had diagnoses including central cord syndrome and neuromuscular dysfunction of the bladder, with a physician’s order for bladder scans every shift and provider notification if residual urine exceeded 200 milliliters. On one evening, the resident’s bladder scan showed 855 milliliters of urine with abdominal firmness, and the physician documented a plan to anchor an indwelling catheter, monitor urine output, clamp the catheter if output exceeded 600 milliliters, and not remove the catheter until the resident was seen by the physician. A subsequent nursing note indicated an on-call provider ordered the catheter to be anchored, with staff to monitor urine output and clamp the catheter if output was greater than 600 milliliters, and confirmed the catheter had been anchored.

Despite these clinical notes, the resident’s record did not contain a corresponding physician’s order for the indwelling catheter, catheter care treatment orders, or orders for monitoring urine output as described in the physician’s note. The January MAR/TAR reflected the high residual urine amount but did not include the detailed catheter-related orders. During interview, the DON stated he could not locate a physician’s order for the indwelling catheter, acknowledged the on-call physician had given the order by phone to anchor the catheter, and indicated staff did not record urine output unless there was a specific physician order. The DON was unaware of the physician’s note directing staff to monitor urine output, and catheter care every shift for residents with indwelling catheters was not documented for this resident.