F0690

D

Failure to Obtain Physician Orders for Indwelling Urinary Catheter After Readmission

Cheswick, Pennsylvania Survey Completed on 04-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain appropriate physician orders for an indwelling urinary catheter for a resident following hospital readmission. The facility’s policy on indwelling urinary catheter care, dated 8/15/25, stated that clinical staff may provide catheter care to help prevent catheter-associated urinary tract infections and prolong the life of the catheter system. The resident, who had diagnoses including repeated falls, anxiety disorder, benign prostatic hyperplasia with lower urinary tract involvement, and a history of lung cancer, had a care plan dated 1/5/26 indicating a history of obstructive uropathy, the need to remain free from catheter trauma, provision of catheter care per routine, and catheter changes per physician order and as needed. Prior physician orders dated 10/27/25 directed staff to provide catheter care, change the suprapubic catheter monthly and as needed, and use an 18 French/10 cc catheter, with documentation of the catheter size inserted; this order ended on 3/25/26.

After the resident was sent to the hospital on 3/25/26 due to respiratory concerns and copious mucus and saliva, he returned to the facility on 3/29/26. Review of physician orders and readmission orders dated 3/30/26 showed there were no active orders for catheter care, catheter sizing, catheter change schedule, or catheter irrigation for this resident, despite the continued presence of the catheter. Observations on multiple occasions on 3/30/26 and 3/31/26 documented the resident in bed with a catheter in place connected to a leg bag, and a nurse aide confirmed the presence of the leg bag. During an interview, the DON confirmed that the facility failed to obtain appropriate physician orders for the resident’s urinary catheter as required by facility policy and state regulations.