HospitalInspections.org

Based on record review and interview, the facility failed to ensure that there were signed physician orders in 2 of 5 urinary catheter insertions (Patient #1 and Patient #4) performed by registered nurses out of a total of 10 medical records reviewed.

Findings include:

Review of Emergency Department record on Patient #1 on 9/26/2017 at 3:50 PM revealed there was no physician order for a urinary catheterization. Emergency Department notes dated 11/25/2015 at 12:48 PM written by Registered Nurse L revealed "Cath UA, clear yellow urine" (use of a one time straight bladder catheter to remove urine to obtain a urine sample).

Observed Foley catheter insertion on 9/27/2017 at 10:12 AM by Registered Nurse M on Patient #4.

Review of Patient #4's operating room record on 9/27/17 at 12:02 PM with Registered Nurse J revealed there was no physician order for Foley insertion.

During interview of Registered Nurse L on 9/27/17 at 9:27 AM, Registered Nurse L confirmed that the facility does not have written standing protocol to obtain specimens for laboratory testing. Registered Nurse L recalled instances where the Laboratory Department would call the Emergency Department to obtain orders on urine that was sent down to the lab without orders.

During interview with CNO B and Executive Director Patient Care Services C on 9/27/2017 at 11:24 AM, CNO B and Executive Director of Patient Care Services C stated that there were no written protocols for patient orders in the Surgical or Emergency Departments on performing a straight catheterization or insertion of Foley catheter. When asked about the missing straight catheterization order on Emergency Room Patient #1, C confirmed there was no order for straight catheterization for urinalysis. When questioned about the missing Foley order on Patient #4 in the Operating Room, C confirmed there was no order for Foley catheter insertion and stated that the physician was present in the Operating Room and the physician should have written the order.