Failure to Implement Orders and Monitoring for Indwelling Urinary Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper orders, care planning, and monitoring for an indwelling urinary catheter for one resident. The resident, an [AGE]-year-old female admitted from an acute care hospital with anemia, elevated white blood cell count, and a complicated UTI, had a documented Foley catheter on admission and throughout her stay. The Five-day MDS showed the resident had an indwelling urinary catheter, moderate cognitive impairment, dependence in ADLs, and was receiving high-risk medications including IV antibiotics for UTI. However, the physician Order Summary Report contained no orders or directions for monitoring or caring for the Foley catheter, and the Care Plan Report did not address the presence, care, or monitoring of the catheter, the UTI, or IV antibiotics. The nurse who completed the admission assessment documented the catheter in the admission note but incorrectly marked the admission data collection tool as negative for an indwelling catheter, and no catheter care orders were entered to generate tasks on the TAR. Review of the TAR for the month showed no orders or directions for catheter care or monitoring. Multiple staff, including the admitting RN, the Subacute Unit Manager, and the DON, later confirmed that the resident had a catheter during the stay and acknowledged that catheter orders were missed and not entered into the record. The facility’s written catheter care policy required that residents with indwelling catheters receive appropriate catheter care every shift and as needed, but this was not implemented for this resident due to the lack of documented orders and monitoring directives.
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