HospitalInspections.org

Based on interview, review of documentation in 2 of 4 medical records of patients who had an indwelling urinary catheter inserted at the hospital (Patients 2 and 3), and review of hospital policies and procedures, it was determined the hospital failed to ensure a RN supervised and evaluated the patient's nursing care needs.
* Nursing assessments related to indwelling urinary catheters were not conducted and documented to evaluate the patient's response to interventions.
* Physician orders for indwelling urinary catheters were not verified and documented in accordance with hospital policies and procedures.

Findings included:

1. The medical record for Patient 3 was reviewed. The record reflected the patient was admitted to the hospital on 12/09/2014 at 1319 for a left hip surgery. The record reflected that on 12/09/14 at 1550 an RN inserted a urinary catheter in the OR.

A physician order dated 12/09/2014 at 1614 reflected "Foley Catheter Insertion." The physician order was recorded 24 minutes after the RN documented that the catheter was inserted.

Documentation on the "Default Flowsheet Data" notes reflected that the patient's catheter was "removed by NOC shift" on 12/10/2014. The catheter "Removal Notes" section was blank. The record lacked documentation reflecting the time the catheter was removed and an assessment at the time of its removal in order to appropriately monitor the patient's response.

2. The medical record for Patient 2 was reviewed. The record reflected the patient was admitted to the hospital on 11/11/2014 at 1053 for a left hip surgery. The record reflected that on 11/11/2014 at 1238 an RN inserted a urinary catheter in the OR.

A physician verbal order dated 11/11/2014 at 1304, and authenticated by the physician at 1348 reflected "Foley Catheter Insertion." The physician order was recorded after the RN documented that the catheter was inserted at 1238.

These findings were reviewed and acknowledged during an interview with the Accreditation and Safety Manager on 02/25/2015 at 1300.

3. A "Lippincott Procedures" document provided titled "Indwelling urinary catheter (Foley) insertion, female" dated "Revised: October 04, 2013" was reviewed. The "Implementation" section reflected the following:
"Verify the doctor's order...Gather the appropriate equipment. Use the smallest bore catheter possible that will support adequate urine drainage(unless otherwise clinically indicated) to minimize bladder neck and urethral trauma." The policy further reflected the following: "Document your assessment findings..."

A "Lippincott Procedures" document provided titled "Indwelling urinary catheter (Foley) insertion, male" dated "Revised: October 04, 2013" was also reviewed. The document included the same language identified in the "Lippincott Procedures" document titled "Indwelling urinary catheter (Foley) insertion, female" above.

4. The policy and procedure titled "Process for Planning & Providing Care" dated last revised "05/2014 reflected "...Each patient will be assessed by an RN...The scope and frequency of reassessment is determined by the patient's condition and responses to care...Routine reassessment frequency is defined by physician order, by policy and procedure/protocol, by standards of care...Documentation of care activities will be done on the Documentation Flow Sheet."