Failure to Provide and Document Ordered Nephrostomy Site Care
Summary
Nursing staff failed to provide and document ordered nephrostomy site care for a cognitively intact resident with an indwelling catheter and nephrostomy. The resident’s Admission/5-day Medicare MDS dated 4/20/2026 showed a BIMS score of 15/15 and documented the presence of an indwelling catheter and nephrostomy. Physician orders dated 4/27/2026 and 4/28/2026 directed staff to cleanse the nephrostomy site with normal saline, pat the area dry, and apply a bandage daily on the night shift and as needed. Despite these orders, the MAR/TAR from 4/14/2026 through 4/27/2026 contained no documentation of nephrostomy dressing changes. Subsequently, a physician order dated 4/30/2026 instructed that the resident be sent to the ED for evaluation and treatment for hematuria. The MAR/TAR from 5/01/2026 through 5/05/2026 then showed documentation of daily nephrostomy dressing changes. During an interview on 5/06/2026, the physician stated that nurses were expected to perform skin and wound care, follow physician orders, and contact the physician as needed, and that in this case the nurses did not do their due diligence. Facility wound care expectations included that wound care procedures and treatments be performed according to physician orders, maintain proper technique, and be documented in the clinical record when performed.
Penalty
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
