F0658

D

Failure to Transcribe and Implement Nephrostomy Tube Orders per Professional Standards

Saint Louis, Missouri Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that services met professional standards when a physician’s orders for a resident with complex renal conditions were not timely or accurately transcribed and implemented. The resident had moderately impaired cognition, an indwelling catheter, a left nephrostomy tube, and diagnoses including renal insufficiency, ESRD, and obstructive uropathy. Hospital transfer/after-visit orders specified that the left nephrostomy tube was to remain clamped and that the dressing was to be changed every 24–48 hours and when soiled, with instructions to contact the genitourinary provider if flank or back pain increased. These instructions were present on the transfer orders and reiterated in a physician progress note shortly after admission, which stated that the left nephrostomy tube should remain in place, be kept clamped, and have the dressing changed every 24–48 hours and when soiled.

Despite these clear instructions, the physician order summary in use at the time of survey showed only an order for nephrostomy tube output every shift starting two days after admission, and did not include an order for dressing changes or for the tube to be clamped until several weeks later. Progress notes during the initial admission period documented that all orders were verified with the physician on the day of admission and that the nephrostomy tube was to remain in place until follow-up with urology, but there was no corresponding active order for clamping or dressing changes on the physician order sheet. Medication and treatment administration records showed that staff were documenting nephrostomy tube output on multiple shifts, which would not be expected if the tube had been clamped as ordered, and there were missed opportunities where output was not documented at all.

Interviews with nursing staff and providers confirmed that the after-visit summary was the source for discharge orders and that nurses were responsible for entering and confirming orders in the electronic system. The nurse manager and NP stated that providers enter their own orders in the computer but nurses must confirm them, and that the general instructions and care of sites should be verified at admission. The NP and RNs interviewed stated that if the nephrostomy tube was properly clamped there would be no measurable output from the tube, and that the dressing should have been changed every 24–48 hours unless orders were changed during verification. Staff also reported that they did not routinely review provider notes unless told there were new orders, and that if a resident returned from an outside appointment without paperwork, the nurse would call the provider and document it. The DON stated that the resident’s orders were verified with the physician on admission, yet the clamping and dressing-change orders were not transcribed onto the physician order sheet in a timely manner, resulting in the nephrostomy tube draining to gravity instead of being clamped as ordered and the absence of a formal dressing-change order during the period reviewed.