Inaccurate Physician Orders for Catheter Type and Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate physician orders and medical records for a resident with an indwelling catheter and no enteral feeding. Facility policy on care and removal of indwelling catheters required staff to evaluate the need for catheter removal by validating the record and physician’s order. For this resident, physician orders dated 10/08/25 included directions to change a suprapubic catheter as needed, monitor output every shift, provide suprapubic catheter care every shift, and administer enteral tube feeding twice a day. The treatment administration record for the same period showed the resident received care for a suprapubic catheter. However, the resident’s annual assessment dated 10/14/25 documented that the resident had a catheter in place, not a suprapubic catheter, and that the resident did not have a tube feeding device and instead ate with supervision or touching assistance. The resident had diagnoses of obstructive uropathy and non-Alzheimer dementia, with severely impaired cognition (BIMS score of 3), and was later discharged for a short-term hospital stay. During interviews, the resident’s representative stated the resident had a catheter upon admission and throughout the stay and was not receiving enteral tube feeding. An LPN confirmed that residents admitted with catheters should have orders specifying the catheter type and size, acknowledged that this resident had a catheter upon admission, and identified that there was no physician order for a catheter, only for suprapubic catheter care, and that the resident was on a regular diet rather than enteral tube feeding. The DON similarly confirmed the resident had a catheter upon admission, that the orders incorrectly specified suprapubic catheter care and lacked an order for the actual catheter, and that the resident was on a regular diet and not nothing by mouth, identifying the enteral tube feeding order as an error. These findings show the resident’s physician orders were inaccurate and inconsistent with the resident’s actual catheter type and nutritional status.
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