Failure to Document Physician Orders for Bladder Scan and Straight Catheterization
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate medical record documentation for a resident who had neuromuscular dysfunction of the bladder and extrarenal uremia. The resident was admitted in mid-November 2025 and required varying levels of assistance with activities of daily living, including toileting and personal hygiene. Review of the resident’s Order Summary Reports for November and December 2025 showed no physician’s order for a bladder scan or for insertion of a straight catheter on an as-needed basis. However, an SBAR Communication Form dated December 8, 2025 documented that an LVN performed a bladder scan on the resident, notified the physician, and received a physician’s order to insert a straight catheter as needed at 12:45 PM that day. During interview and concurrent record review, the LVN confirmed performing the bladder scan and obtaining a physician’s order for straight catheterization to drain urine as needed, but acknowledged that there was no documented order in the medical record for either the bladder scan or the straight catheter on that date and stated that this documentation should have been completed. The DON also stated that the nurse should have obtained and documented a physician’s order to perform the straight catheter. Facility policies on Charting and Documentation required that all services provided and changes in condition be documented in the resident’s clinical record, and the Electronic Signatures and Electronic Orders policy required that the time and date of orders entered or changed in electronic records be recorded. The lack of a documented physician’s order for the bladder scan and straight catheterization on December 8, 2025 resulted in inaccurate documentation in the resident’s medical record and had the potential for delaying interventions and services for the resident.
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