Lack of Physician Order Specifications for Foley Catheter
Penalty
Summary
The facility failed to obtain and document physician order specifications for the size of the indwelling Foley catheter and the balloon inflation amount for one resident. According to the facility's Foley Catheter Care policy, physician orders for catheter use must include the bulb and catheter size, frequency of catheter changes, and catheter care instructions. However, a review of the clinical record for a resident admitted with diagnoses including dysphagia, chronic kidney disease, and urinary retention revealed that the physician orders only specified the frequency of catheter changes, use of a dignity cover, and irrigation instructions, but did not include the required catheter size or balloon inflation amount. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the clinical record lacked the necessary specifications for the indwelling catheter. The deficiency was identified for one of three residents reviewed for catheter care, indicating noncompliance with both facility policy and regulatory requirements regarding proper documentation and physician orders for catheter use.