Lack of Physician Orders for Catheter Care for Residents With Indwelling Urinary Catheters
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents with indwelling urinary catheters had physician orders that included catheter care instructions, as required by facility policy. The catheter care policy, revised 8/1/25, stated that residents with indwelling catheters would receive catheter care every shift and as needed, drainage bags would be emptied when half-full or every three to six hours, and drainage bags would be kept below bladder level. For one resident with mild cognitive impairment, high blood pressure, kidney failure, neurogenic bladder, bilateral lower extremity impairment, and use of a wheelchair, the electronic physician orders in November 2025 showed discontinuation of orders for monthly Foley catheter and drainage bag changes, catheter care, and catheter privacy covering. The resident’s quarterly MDS still documented an indwelling urinary catheter, and the care plan in use during the survey included a focus on Foley catheter care with an intervention to provide catheter care every shift. Despite the care plan, the resident’s physician orders did not include catheter care until new orders were entered in January 2026 for Foley catheter to gravity drain, catheter care every shift, weekly catheter anchor changes, and use of a leg bag when out of bed. Observations over multiple days showed the resident in an electric wheelchair with the catheter drainage bag hanging from the right armrest. For another resident with a diagnosis including benign prostatic hyperplasia with lower urinary tract symptoms, the care plan identified the presence of a urinary catheter and directed catheter care every shift, but physician order sheets from 12/31/25 through 1/3/26 contained no catheter care orders. In interviews, an RN and the DON stated that all residents with urinary catheters were expected to have catheter care orders in place, and that such orders should be entered on admission, confirming that the absence of these orders for two residents did not meet facility expectations.
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