Failure to Obtain Physician Orders for Foley Catheter Care
Penalty
Summary
A deficiency occurred when a resident who was admitted with a Foley catheter did not have physician orders in place to address the treatment and services required for catheter care. The resident, a male with quadriplegia, neurogenic bladder, and a Stage 2 pressure ulcer, was dependent on staff for toileting hygiene and had a catheter in place throughout the assessment period. Review of the resident's care plan and physician orders revealed that neither addressed the Foley catheter, and the only documentation related to catheter care was a nurse practitioner note instructing to ensure catheter securement to prevent pressure. Interviews with nursing staff and facility leadership confirmed that the admitting nurse did not obtain the necessary orders for the Foley catheter, and subsequent follow-up by the ADON and Regional Compliance Nurse failed to identify and correct the omission. Staff acknowledged that the lack of physician orders could result in missed care and increase the risk of infection. The facility's policy required nurses to review and clarify orders as needed, but this process was not followed, resulting in the deficiency.