Failure to Follow Physician Order for Catheterization
Penalty
Summary
Nursing staff failed to follow a physician's order for straight catheterization for a resident who was admitted after joint replacement surgery and had a diagnosis of urinary retention. The physician's order specified that if the resident was unable to urinate after six hours, a bladder scan should be performed, and if the residual volume was greater than 450 ml, a straight catheterization should be done as needed. Instead, when the resident complained of inability to urinate and bladder pain, staff inserted a Foley catheter for continuous urinary drainage without a physician's order for this intervention. There was no documentation in the clinical record of a physician order for the Foley catheter, no order for catheter care, and no record of the date and time of insertion. Additionally, no care plan was initiated to address the presence of the Foley catheter. The resident and family expressed concerns about the use of the Foley catheter, and the DON confirmed that staff did not follow the physician's order and inserted the Foley catheter without proper authorization.