Failure to Follow Physician Order for Foley Catheter Removal
Penalty
Summary
A deficiency occurred when a resident with diagnoses including repeated falls, dementia, benign prostatic hyperplasia, and urinary retention with an indwelling Foley catheter did not receive care in accordance with physician orders. The resident had an order for the removal of the Foley catheter on a specified date, with instructions for nursing staff to perform intermittent bladder scans and to consult urology or send the resident to the emergency room if urinary retention was extreme. However, the night shift nurse did not remove the catheter as ordered, expressing concern about the resident being without a catheter for an extended period. As a result of the nurse's failure to follow the physician's order, the scheduled urology appointment for catheter removal and evaluation had to be rescheduled. Both the Registered Nurse and the Director of Nursing confirmed that the nurse should have adhered to the physician's instructions regarding catheter removal. This lapse resulted in the resident not receiving timely and appropriate treatment and services as required.