Foley Catheter Changed Without Provider Order
Penalty
Summary
A deficiency occurred when a resident with a history of benign prostatic hyperplasia, urinary retention, urinary tract infection, and an indwelling Foley catheter experienced pain and lack of urine flow from the catheter. Nursing documentation indicated that the nurse attempted to flush the catheter without relief and subsequently changed the Foley catheter, noting the resident's pain was relieved and urine output was restored. However, there was no evidence in the clinical record of a provider order authorizing this as-needed catheter change. Interviews with nurse practitioners confirmed they were not aware of the catheter change at the time and had not provided an order for it. The LPN involved stated she used a PRN order to change the catheter but did not verify the existence of such an order prior to the intervention.