Failure to Follow Foley Catheter Discontinuation Order
Penalty
Summary
The facility failed to follow a physician’s order to attempt removal of an indwelling Foley catheter for a resident. The resident was admitted with diagnoses including bacteremia, hypertension, cellulitis, type 2 diabetes mellitus, and osteomyelitis, and a quarterly MDS indicated the resident was cognitively intact. A physician’s order dated 12/30/25 directed staff to clamp the Foley catheter for four hours, release for 15 minutes, repeat for 24 hours, then discontinue the Foley. The order further specified that if the resident did not void, staff could perform straight catheterization every four to six hours and as needed, and if the post-void residual exceeded 500 milliliters twice, the Foley should be replaced. Review of the medical record showed no documentation that the Foley catheter was removed or that removal was attempted as ordered on 12/20/26. Progress notes instead showed that the Foley was removed on 01/06/25 per order, and the resident was sent to the ER for elevated temperature, elevated pulse, and decreased blood pressure. During an observation and interview, the resident was noted to have an indwelling Foley in place and reported that a nurse had told him the Foley “didn’t look right.” In an interview, the Administrator and DON confirmed there was no documentation of the Foley being removed or of any attempt to remove it, and the DON stated she thought the Foley had been removed and reinserted but acknowledged there was no documentation. This constituted a failure to ensure appropriate Foley catheter care as ordered.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.