F0658

E

Failure to Follow Physician Orders for Catheter and Wound Care

Natchitoches, Louisiana Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure services met professional standards of quality for residents with suprapubic catheter and wound care needs. One resident with multiple diagnoses including Type 2 diabetes, UTIs, cellulitis of both lower limbs, venous insufficiency, neuromuscular bladder dysfunction, and bowel and bladder incontinence had a physician order dated 09/15/2025 for a suprapubic catheter change every month and PRN for leakage/occlusion, with the GU bag to be changed on the 15th of each month. Review of the November and December Treatment Administration Records (TARs) showed that the scheduled suprapubic catheter changes on 11/15/2025 and 12/15/2025 were not documented as completed, and there was no documentation or progress note explaining why the catheter was not changed. The LPN responsible for treatments and the Unit Manager both confirmed, after reviewing the TARs, that the catheter had not been changed in those months despite the standing order and the facility expectation that missed treatments be documented with a reason.

The same resident was also followed by an external wound care clinic for a left posterior gluteal pressure ulcer. A wound care clinic physician note dated 01/02/2026 documented an open Stage 3 pressure ulcer on the left posterior gluteus, with orders to cleanse with normal saline once daily, apply a topical antibiotic compound once daily when available, and cover with a 6x6 border gauze dressing once daily. Review of the resident’s January 2026 physician orders and TAR revealed no orders entered for treatment of this left posterior gluteal pressure ulcer and no documentation that the ordered wound care was performed. During interview, the treatment RN stated that she receives and inputs wound care clinic orders into the computer and adds them to the facility’s orders and TAR, and that the resident never refuses wound care. However, observation on 01/14/2026 showed the resident had an open wound on the left posterior gluteus with no dressing or bandage in place, and the treatment RN confirmed there were no other treatment orders for this wound beyond application of Calazinc cream to the buttocks and groin.

Another resident with diagnoses including Type 2 diabetes with skin ulcer, non-pressure chronic ulcer of the right heel and midfoot, CKD stage 3A, Charcot joint of the left ankle and foot, depression, and an unspecified open wound of the left foot had physician orders for wound care that included cleansing with normal saline, applying ointment to the wound bed, covering with sterile gauze, and wrapping with Kerlix secured with tape. The report identifies this as an additional instance where physician wound care orders were not followed, contributing to the overall finding that the facility failed to provide care and services in accordance with professional standards of quality for wound and catheter management for sampled residents.