Failure to Follow Foley Catheter Change Orders for Resident With Urinary Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and catheter care for a resident with significant urinary conditions. The resident was admitted with diagnoses including infection and inflammatory reaction due to an indwelling ureteral stent, calculus of the kidney and ureter, and obstructive and reflux uropathy. Physician orders dated 08/23/25 included changing the Foley catheter every 30 days, providing Foley catheter care every shift, changing the catheter as needed for leakage or drainage, and irrigating the catheter as needed. Record review showed that on 09/08/25 staff documented the resident refused a catheter change, and on 10/22/25 staff documented that the Foley catheter was changed. Further record review of the MARs for November and December 2025 revealed no documentation that the resident’s Foley catheter was changed during those months. An LPN stated that Foley catheters are typically changed every 30 days and acknowledged that the order for a 30‑day catheter change had been incorrectly entered and automatically discontinued on 09/09/25, resulting in the catheter being changed only once since 08/23/25. The ADON confirmed that Foley catheters should be changed every 30 days unless otherwise ordered, that the resident’s 30‑day catheter change order was incorrectly entered and discontinued, and that the catheter was only changed once on 10/22/25, despite expectations that staff ensure Foley catheters are changed as ordered.
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