Failure to Follow Physician Orders for Catheter Care and Oxygen Therapy
Penalty
Summary
The facility failed to follow multiple physician orders for one resident with diagnoses including obstructive and reflex uropathy, urine retention, and atrial fibrillation. Physician orders dated September 5, 2025, directed that Foley catheter care be provided every shift. Review of the resident’s December 2025 and January 2026 MARs showed numerous shifts on which Foley catheter care was not documented as provided, including multiple day and evening shifts across both months. The resident also had physician orders dated October 30, 2025, for continuous oxygen at 2 liters via nasal cannula every shift for shortness of breath, and orders dated September 4, 2025, to keep the head of the bed elevated every shift to prevent shortness of breath while lying flat. Review of the December 2025 and January 2026 MARs revealed that these oxygen and head-of-bed elevation orders were not followed on the same multiple day and evening shifts where Foley care was missed. During an interview on January 8, 2026, at 10:05 a.m., the DON was presented with this information and confirmed that the physician orders had not been followed.
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