Lack of Physician Orders for Foley Catheter Use and Care
Penalty
Summary
The deficiency involves the facility’s failure to obtain and maintain physician orders specifying the necessity, type, and care of a Foley catheter for a resident with an indwelling catheter. The resident was admitted with diagnoses including lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism. Review of the physician orders showed no orders for the use of a Foley catheter or for catheter care, despite documentation elsewhere indicating catheter use. The resident’s MDS dated 12/25/25 documented the presence of a catheter in Section H, and the care plan dated 12/19/25 stated the resident required a Foley catheter due to skin impairment. During a random observation of the resident’s room, surveyors observed a tube connected to a bag containing what appeared to be urine hanging from the bed, consistent with a Foley catheter. In a subsequent interview, the resident confirmed that she uses a Foley catheter. The Interim DON later confirmed that the resident did not have physician orders for the use of a Foley catheter or for catheter care, despite the documented and observed presence of the catheter.
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