Failure to Ensure Proper Physician Order and Catheter Specification
Penalty
Summary
The facility failed to ensure a proper physician order for an indwelling urinary catheter for a resident with obstructive and reflux uropathy, dementia, and benign prostatic hyperplasia. The physician order on file directed staff to change the Foley catheter every 90 days but did not specify the type or size of the catheter to be used. The resident's care plan indicated the use of a 16 French catheter with a 10 ml balloon, but this information was not reflected in the physician order. During care, staff referenced the care plan for catheter specifications rather than a physician order, and a registered nurse provided a stock 14 French catheter with a 30 ml balloon, stating she would only use 10 ml of saline in the balloon to match the care plan, not the actual balloon size. The director of nursing confirmed that staff were expected to follow physician orders and document all relevant details during catheter changes, but acknowledged that using a 30 ml balloon with only 10 ml of saline was not in accordance with the order. Interviews revealed that the nurse practitioner expected staff to have a specific order for a 16 French catheter with a 10 ml balloon and to follow it accordingly. The facility's policy on catheter-associated UTI prevention described the insertion procedure but did not address the requirement for a physician order specifying catheter type and size. The lack of a clear, specific physician order and reliance on the care plan for catheter details led to inconsistencies in catheter care and documentation for the resident.