Catheter Replaced Without Physician Order Resulting in Complications
Penalty
Summary
A deficiency occurred when a resident with a history of obstructive and reflux uropathy and urinary retention, who had an indwelling Foley catheter per physician order, had their catheter replaced by a registered nurse without a physician's order. The resident's care plan included monitoring for urinary tract infection and the physician's order specified the use of an 18 French Foley catheter with a 10 cc balloon, with a scheduled urology appointment for catheter replacement. Despite these instructions, the nurse removed the existing catheter and inserted a different type and size (16 French, 5 cc balloon, coude tip) after observing low urine output and unsuccessful flushing, without consulting the physician or obtaining a new order. Following the catheter change, the resident exhibited significant swelling of the genitalia and hematuria, prompting transfer to the emergency room, where the diagnosis was pyelonephritis. Record review confirmed there was no physician's order for the catheter change prior to the scheduled appointment, and the Director of Nursing Services confirmed that the nurse should have contacted the physician for further recommendations rather than proceeding with the catheter replacement.