Failure to Follow Physician Order for Foley Catheter Size
Penalty
Summary
A review of facility policies, clinical records, and staff interviews revealed that the facility failed to implement appropriate treatment and services for incontinence management for one resident. Specifically, the physician's order for the resident indicated the use of a Foley catheter sized 18 French (Fr) with a 60 cc sterile saline irrigation as needed for blockage. The resident's care plan also documented the use of an 18 Fr Foley catheter. However, during an observation, it was found that the resident had a Foley catheter of size 14 Fr with a 30 cc balloon in place, which did not match the physician's order or the care plan. This discrepancy was confirmed at the time of observation with a licensed nurse. The failure to provide the correct catheter size as ordered by the physician constituted a deficiency in the facility's incontinence management and nursing services.