Failure to Follow Physician Orders for Indwelling Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter by not following the physician's order regarding the correct catheter size. The resident, who was admitted with urinary retention and obstructive and reflux uropathy, was severely cognitively impaired and dependent on staff for activities of daily living. The physician's order specified a Foley catheter of 16 French with a 10 ml balloon, to be changed as needed for signs and symptoms of infection and routinely once a month. During observation, it was found that the resident had a 14 French Foley catheter in place, and the balloon size was faded and unreadable. Review of the Treatment Administration Record indicated that the catheter change was documented as completed with the correct size, but in reality, the catheter had not been changed as ordered. The Director of Nursing confirmed that the catheter in use did not match the current physician's orders and that the required catheter change had not occurred.