F0600

J

Failure to Follow Foley Catheter Orders and Notify Physician of Changes Resulting in Harm to Two Residents

Whigham, Georgia Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary care and services in accordance with physician orders and to notify the physician promptly of significant changes in condition for two residents with Foley catheters. Facility policies required protection from abuse, neglect, and exploitation, prompt notification of changes to physicians and resident representatives, and obtaining a physician or nurse practitioner order prior to Foley catheter irrigation. Despite these policies, staff actions and omissions related to Foley catheter insertion, irrigation, removal, and follow-up care did not comply with physician orders or notification requirements.

For the first resident, who had diagnoses including hypertension, GERD, type 2 diabetes mellitus, an orthopedic implant in the left leg, and morbid obesity, the physician had ordered aspirin and Foley catheter care every shift due to wounds. On the day of the incident, an LPN inserted a Foley catheter at the end of the day shift and noted urine return with a small trace of blood. The resident became panicked upon seeing blood in the Foley tubing, and the LPN irrigated the Foley catheter with sterile water without obtaining a physician order, stating that Foley irrigation was basic nursing. Later, during the evening shift, a CNA observed that there was no urine output and blood in the Foley drainage bag and reported this to the assigned LPN. The LPN did not notify the physician about the blood in the Foley drainage bag.

Instead of obtaining a physician order, the LPN removed the Foley catheter based on instructions relayed from the former DON, despite having no physician order to discontinue the catheter. After removal, the resident began bleeding from the penis and rectum and developed altered mental status and loss of consciousness. EMS was called and documented that the resident had been bleeding from Foley catheter removal and was experiencing shortness of breath, later becoming unresponsive and going into respiratory arrest. Hospital records indicated that the resident had a Foley catheter placed earlier that day with a large amount of blood expressed and that the onset of shortness of breath coincided with the Foley procedure. The resident was transferred to a second hospital in critical condition, where a urologist placed a Foley catheter with cystoscopy, and bleeding continued from multiple sites. The death certificate listed acute cardiac and respiratory failure, disseminated intravascular coagulation, and urethral injury as the immediate cause of death.

For the second resident, who had diagnoses including HIV, morbid obesity, obstructive and reflux uropathy, anemia, chronic pain, hypertensive heart disease, cerebral infarction affecting the left dominant side, uropathy, and an indwelling Foley catheter, the physician ordered a urine sample for urinalysis and culture and removal of the Foley catheter. After admission, the Foley catheter was discontinued, but due to urinary retention concerns it was reinserted, and an order was obtained for UA/C&S and a urology consult because the urine was cloudy with a foul odor. The resident also had orders for a routine monthly catheter change with an 18 Fr 10 cc balloon and to irrigate the catheter with 60 cc normal saline or sterile water as needed for leakage or blockage every eight hours as needed for urinary retention. A laboratory requisition for urinalysis with microscopic sample was dated, but there was no evidence that the urine sample was collected as ordered.

Further review of the second resident’s records showed a handwritten lab requisition noting that the resident was discharged to the hospital on a certain date, but there was no documentation in the medical record that the resident was sent to the hospital, and the census did not reflect a leave of absence. There was no indication that the ordered urine specimen was obtained, although a urology appointment was scheduled and later rescheduled. Hospital records documented that the resident was admitted from the nursing home with altered mental status and concern for sepsis, with a chronic indwelling Foley catheter and a history of complicated UTIs. The urinalysis showed extremely turbid urine with high leukocyte esterase and elevated WBCs. The resident was discharged back to the facility with a Foley catheter changed in the emergency department and no antibiotics ordered. Later, facility progress notes documented altered mental status and transfer to the hospital via EMS, where hospital records indicated hypotension and septic shock likely from a UTI or infected decubitus ulcer/osteomyelitis, and that the Foley catheter had reportedly been in place for more than a month. The death certificate listed urosepsis and pneumonia as the immediate cause of death.

Staff interviews confirmed the deviations from policy and physician orders. The LPN who inserted the Foley for the first resident acknowledged irrigating the catheter without an order. The CNA on the evening shift reported observing no urine output and significant bleeding from the resident’s penis and rectum and expressed concern that the assigned LPN was not doing enough, prompting her to ask another LPN to call the former DON. The assigned LPN for the first resident confirmed that she removed the Foley catheter without a physician order, following the former DON’s instructions, and that she only texted the physician after deciding to send the resident to the hospital. Another LPN reported that the former DON, overhearing the situation by phone, first instructed that the Foley be flushed and then instructed that it be removed, with the plan to obtain a discontinuation order afterward. For the second resident, an RN stated that she had not changed the Foley catheter on the date the resident was sent to the hospital, and that she noted low oxygen saturation, reported it to the charge nurse, and called the physician, who ordered transfer to the ER.