F0835

J

Failure of Administrative Oversight for Physician Orders, Catheter Care, and Equipment Safety

Whigham, Georgia Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure of administrative oversight by the former Administrator and Director of Nursing to ensure physician orders were obtained and implemented as written, and to adequately supervise the quality of care. The Administrator’s job description required leading and directing operations in accordance with regulations and facility policies to provide appropriate care, and the Director of Nursing’s job description required directing nursing services in line with standards and physician direction. Despite these responsibilities, the facility did not ensure that nursing staff followed proper procedures for obtaining and carrying out physician orders, nor did it ensure that equipment used for resident care was safe and removed from service when malfunctioning.

For one resident with diagnoses including hypertension, GERD, type 2 diabetes mellitus, an orthopedic implant, and morbid obesity, an LPN inserted a Foley catheter and, after noting bleeding in the tubing, irrigated the catheter with sterile water without a physician order. Later that day, a CNA reported to another LPN that the resident had no urine output and blood in the Foley drainage bag. The LPN did not notify the physician of these findings and removed the Foley catheter based on instruction from the former DON, without any physician order or documentation of such an order. After removal, the resident began bleeding from the penis and rectum, experienced altered mental status and loss of consciousness, and was subsequently sent to a hospital.

For another resident with diagnoses including HIV, morbid obesity, obstructive and reflux uropathy, anemia, chronic pain, hypertensive heart disease, cerebral infarction affecting the left dominant side, and an indwelling Foley catheter, physician orders to obtain urine samples for urinalysis and culture were not carried out as written. The Foley catheter was removed per order, but the ordered urine sample was not collected. A subsequent order to reinsert a Foley catheter due to retention concerns, obtain a UA/C&S, and arrange a urology consult for cloudy, foul-smelling urine was also not fully implemented, as there was no evidence the urine specimen was obtained. Documentation was inconsistent regarding a noted discharge to the hospital, with no supporting record or census entry. Later, this resident was admitted to a hospital with altered mental status and concern for sepsis, had a Foley catheter replaced in the ER, and was again sent to the hospital with labored breathing and admitted with septic shock and a complicated UTI. Additionally, the facility allowed continued staff use of a malfunctioning Hoyer lift, which resulted in another incident where a resident fell when the lift tilted during transfer, followed by complaints of pain and negative x-rays the next day.

The facility’s Quality Assessment and Assurance process documented multiple falls in consecutive months, but there was no evidence that other residents fell due to the malfunctioning Hoyer lift. The current Administrator, hired later, stated an expectation that all residents receive excellent care and reported being unaware of these incidents. The former Administrator and former DON were unavailable for interviews, leaving the documented record and staff accounts as the primary evidence of the failures in obtaining and implementing physician orders, monitoring resident condition changes, and removing malfunctioning equipment from use.