Foley Catheter Removed Against Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a physician order specifying that their Foley catheter should not be manipulated, flushed, or exchanged, and that only urology should address any issues, had their catheter removed by a registered nurse. The nurse observed that the resident's bed was wet, the catheter was not draining properly, and only 3mL of fluid was present in the balloon upon aspiration. Despite being aware of the explicit order not to manipulate or remove the catheter and to contact urology for any issues, the nurse proceeded to remove the catheter without first consulting a provider or urology. The nurse attempted to contact the primary provider and urology only after the removal had already occurred. Interviews confirmed that the nurse was aware of the standing orders and the facility's policies requiring physician notification and authorization for significant changes in treatment, including catheter removal. The urology clinic confirmed that an afterhours contact was available and that the catheter should not have been removed by facility staff. The Director of Nursing acknowledged that the nurse did not consult with a provider prior to removal and that the event took place before the clinic opened. The facility's failure to follow physician orders and internal protocols led to the deficiency.