Failure to Follow Physician Orders for Indwelling Urinary Catheter Size
Penalty
Summary
Facility staff failed to follow physician orders regarding the size of an indwelling urinary catheter for a resident with urinary retention, neurogenic bladder, and other urological conditions. The resident was cognitively impaired, dependent on staff for activities of daily living, and had a physician order specifying the use of a 14 French (Fr) Foley catheter. However, during observation, the resident was found with a 16 Fr/5 ml catheter in place, contrary to the physician's order. There was no documentation indicating that the physician or physician assistant had been notified or consulted about the use of a different catheter size. Additionally, the medical record did not contain an order specifying the balloon size or volume for the catheter, which was noted as necessary by the Director of Nursing. The care plan and physician orders required monthly catheter changes and specified the use of a 14 Fr catheter, but these were not followed. The resident reported experiencing pain with the indwelling catheter, and staff interviews confirmed that the correct catheter size was not used and that the required physician orders for balloon size were missing.