Failure to Perform Ordered Foley Catheter Change
Penalty
Summary
A deficiency occurred when a resident with a Foley catheter did not receive the required monthly catheter change as ordered by the physician. The resident, who had a history of stroke, diabetes, dementia, neurogenic bladder, and obstructive uropathy, was dependent on staff for mobility and had severely impaired cognitive skills. The physician's order specified that the Foley catheter should be changed every month on the 13th, and the care plan reflected this requirement. However, documentation by an RN indicated that the catheter was changed, but in reality, only the catheter bag was replaced due to leakage, and the catheter itself was not changed. Interviews with the RN and the DON confirmed that the catheter was not changed as ordered, and the DON was unaware of the missed change until questioned. The resident's family member also reported not observing a catheter change and was told conflicting information by staff. The facility's catheter care policy emphasized the importance of proper catheter management to reduce complications, but the required procedure was not followed for this resident.