Failure to Follow Physician Orders for Catheter Supplies and Sizes
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders by not having the correct catheter supplies available upon admission and by using alternate catheter sizes without physician orders for two residents with indwelling catheters. One resident with a spinal cord injury, neuromuscular bladder dysfunction, and depression was admitted with an order for catheter changes every four weeks and as needed, and a care plan identifying a urinary catheter for obstructive uropathy. Progress notes documented that staff did not have a Foley catheter clamp available when the resident requested a tub bath, so they used tape to kink and clamp the catheter. Later, when attempting to flush the catheter, staff found it plugged and discovered the correct catheter size was not in stock. The resident had a 20 French catheter with a 10 cc balloon in place, but staff replaced it with an 18 French catheter with a 10 cc balloon instead of the ordered size. A second resident admitted with diagnoses including UTI, urinary retention, and chronic kidney disease had a physician order for a one-time insertion of a 14 French catheter with a 5 cc balloon. Progress notes indicated that staff informed the family they did not have a 14 French catheter available and therefore replaced it with a 16 French catheter with a 10 cc balloon. Interviews with an RN and the DON revealed that the person entering admission orders was expected to check supply availability and that the DON was responsible for ensuring the correct catheter sizes were in stock. The DON acknowledged that the correct catheter size was not available for the first resident at admission, that a different size was used without obtaining a physician order, and that she was not aware the correct size was also unavailable for the second resident. Facility policy stated that all physician orders were to be followed as prescribed and that any orders not followed should be documented in the medical record during that shift; the facility’s policy on physician notification of changes in orders was requested but not provided.
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