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Based on staff interviews, review of medical record, and review of facility policy, it was determined that the facility failed to ensure all urinary catheters are used with provider orders as per facility policy.

Findings include:

Facility policies and Patient (P)1's medical record was reviewed on 03/26/2024 at 10:56 AM in presence of Staff (S)1, Patient Safety and Quality Manager; S2, Director of Patient Care Services; S3, Emergency Department (ED) Nurse Manager; S4, Supervisor of Mental Health; and S7, Assistant Nurse Manager of ED. Findings revealed the following:

On 10/10/2023 at 8:07 PM, S10, ED Physician entered an order for a urine culture and urinalysis for P1. The ED timeline for specimen collection states, " ...Type: Urine; Source: Urinary Bladder." Urine specimen collected by S13 (Registered Nurse) on 10/10/2023 at 8:50 PM. When asked how they would interpret the method of obtaining urine under this wording, S3 states "This would indicate a urinary catheter. If the urine was provided naturally in a cup, it would state 'clean catch.'" When asked if they have discussed this event with S13, S3 stated "Yes, I confirmed with the nurse that the patient was straight cathed [catheterized]...."

S13's genitourinary (GU) assessment of P1 from 10/10/2023 at 8:53 PM states, " ...Urinary Status: Straight cath [catheterization] (200ml [milliliters])." There was no order for straight catheterization in P1's medical record.

During an interview at 2:26 PM, S7 was questioned if a physician's order is necessary prior to straight catheterizing a patient for a urine specimen. S7 confirmed that an order is needed. Policy titled "Urinary Catheter/GU Management (last revised 1/2021) states, " ... A provider order is required at insertion ... of all urinary drainage catheters ..." Findings confirmed with S7 at 2:30 PM.