Incorrect Foley Catheter Size Used and Physician Order Not Followed
Penalty
Summary
The deficiency involves failure to provide catheter care and treatment in accordance with professional standards for a resident with an indwelling urethral catheter. The resident was admitted with an order for an 18 French Foley catheter to be changed every four weeks. On one evening, a registered nurse documented changing the resident’s Foley catheter, and later that same evening, the resident requested that another registered nurse flush the catheter. When the second nurse rechecked the resident a couple of hours later, there was no urine output despite the resident having consumed over 400 cc of water. Upon assessment, the second nurse observed that the catheter in place was a size 20 French, not the ordered 18 French. The second nurse later stated that when she attempted to adjust the catheter due to the resident’s discomfort, she noticed the catheter was larger than ordered. The nurse who performed the catheter change acknowledged she had used a 20 French catheter because she could not find an 18 French in the facility and did not notify anyone at the facility or the provider about this deviation from the physician’s order. The Director of Nursing Services confirmed that physician orders should be followed and acknowledged that the wrong catheter size had been used for this resident.
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