Foley Catheter Anchored Without Physician Order Leading to Urethral Bleeding and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a nurse obtained a physician’s order prior to inserting and anchoring a urinary (Foley) catheter for a resident who was being evaluated for possible UTI and sepsis. The resident had diagnoses including hypertension, iron deficiency anemia, sequelae of cerebral infarction with hemiplegia, chronic pain syndrome, hypokalemia, prior UTI, and bandemia, and was always incontinent of bowel and bladder. On the day of the incident, staff noted blood in the resident’s urine, burning with urination, altered mental status, low blood pressure, and a low‑grade temperature. The on‑call NP was notified and gave orders for IV fluids, labs, and a urinalysis with culture and sensitivity, but there was no order documented for insertion or anchoring of a Foley catheter. Earlier in the day, the DON started an IV due to the resident’s low blood pressure and change in condition, and staff were instructed to obtain a urine specimen. Multiple nurses, including the DON, RN 21, and LPN 3, later stated that for an incontinent resident they would normally obtain a clean‑catch specimen if possible or perform a straight (in‑and‑out) catheterization for a urinalysis, and that they would not anchor a Foley catheter for this purpose. They also indicated that a physician’s order and an appropriate diagnosis were required before inserting and anchoring a Foley catheter. The Administrator and DON confirmed that nurses needed a physician’s order to anchor a Foley catheter, and the Senior Regional Director of Clinical Services reported there was no policy related to physicians’ orders. Despite this, LPN 13 reported that when she worked with the resident that day, aides told her the resident, who was normally incontinent, had been dry and she believed he was probably dehydrated. She inserted the smallest catheter available but did not obtain urine return, then decided to inflate the 10 cc balloon and leave the catheter in place rather than attempting catheterization again, even though there was no physician’s order for a Foley catheter. The resident, who did not normally have a catheter, was in pain. Later, RN 19 came on duty, found the catheter anchored, and when lab staff arrived he deflated the balloon and removed the catheter to obtain the urine sample. Following removal, the resident began bleeding profusely from the urethra, and the on‑call NP was notified and the resident was sent to the hospital, where he was admitted with septic shock, UTI, and urosepsis and had a 16 French catheter inserted.
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