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Based on observation, interview and record review, the facility's registered nurses failed to secure physician's orders for care and services ( insertion of Foley Catheter) provided to 2 of 10 sampled patients. Patient #s 6 and 1.

Findings:

Patient #6

Patient #6 was observed in her room on 08/06/2019 at 11:45 a.m., the Patient was alert with periods of confusion. The Patient had a Foley catheter in place to bedside drain with approximately 500 mls of clear amber urine;

On 08/06/2019 at 11:55 a.m., the Surveyor reviewed the Patient's clinical record in the electronic medical record with Licensed Vocational Nurse (B).
Review of the Patient's clinical record revealed a physician's order dated 08/02/2019 for urinalysis and urine culture.

Review of the clinical record revealed no evidence of a physician's order to insert a Foley catheter in the patient.

Interview on 08/06/2019 at 11:56 a.m. with Licensed Vocational Nurse (B) revealed the Patient's Foley catheter was inserted in the emergency room but she could not locate a physician's order for the Foley catheter.

Patient #1

Review of the Patient #1's medical record revealed, the Patient was admitted to the facility on 6/4/2019 at 0236. The Patient was seen and examined in the facility's emergency center with chief complaint of vomiting, fever and diarrhea. She was triaged at 02:36 a.m. as a level 4 semi- urgent. The Patient's documented temperature in the emergency center was 100.4 F.

Review of Registered Nurse (H's) Nurses notes
Review of a nurse's notes dated 06/04/2019 at 03.44 a.m. revealed the following entry by Registered Nurse ( H) : "Due to fever - and I attempted urine cauterization per sterile technique. Mother became tearful during procedure so Dr (D) said it was not necessary.
Soon after grandmother of patient called nurse's station and was very angry. She requested all our names working but I gave her mine. I gave her administration's number, so she could make a complaint. Grandmother was upset that we attempted urine cath on baby and stated, "you don't do that to little girls" to me several times on the phone. I apologized to her and stated that, that was the standard of care for urine collection in the ED to get a clean urine specimen. She was not ok with my response and continued to say that, "y'all shouldn't make mistake like that and hurt little girls." She also stated that "this isn't the first time ---- hospital has made big mistakes." Again, I apologized to grandmother."

Review of the Patient's Physician's orders
Review of the Patient's clinical record revealed the following physician's orders:
"Ceftriaxone 500 Mg (Rocephin) 500 mg IM x 1.
Influenza Screen X 1
Ibuprofen 100 mg/ 5 ml liq (Motrin) 100 MG PO X 1
Ondansetron ODT 4 MG tab (Zofran ODT) 2 MG PO X 1
Acetaminophen 160 MG / 5 ml susp (Tylenol) 120 MG PO X1

Review of the Patient's clinical record revealed there was no physician's order documented for insertion of a Foley catheter and urine specimen collection on the Patient.

Review of signed statement from Physician D
Review of a signed statement from Physician (D) dated 7/11/2019 revealed the following documentation: "Urine sample was not ordered. My words were misinterpreted, RN thought we should collect for patient #1 when UA was ordered for another ER patient. Patient #1 did not sustain any harm because the single cath attempt was not successful. The catherization attempt was a mistake. I went into patient's room and stopped another cath attempt before RN can try it again."

Reviewed Facility's Policy and Procedure
Review of the Facility's current policy and procedure on Foley Catheter Insertion and Removal Protocol, effective 5/2015, revealed no documentation in the Policy and Protocol that the indication for insertion of a Foley catheter was diagnosis or presenting symptom of fever.

Reviewed Facility's Complaint / grievance log
Review of the facility's complaint grievance log, dated 06/04/2019 revealed documentation of a grievance from Patient #1's relative stating that a doctor ordered a Foley catheter on a one-year old child. "Nurse could not insert, and baby is now hurting."

Interviewed Registered Nurse (H)
During an interview on 08/06/2019 at 10:17 a.m. with Registered Nurse (H) revealed, Patient #1's mother brought the patient to the emergency room because she was running a fever. The Registered Nurse said she placed the Patient in bed and did vital sign checks on the Patient. She said because of the Patient's age and presenting symptom, she asked the mother if she could do a rectal temperature on the Patient. The mother did not respond. After completion of the vital signs, she weighed the Patient and did a physical examination on the Patient.

She said the Physician then directed her to do a flu and RSV swab on the patient. She explained to the Patient's mother what she was about to do.
She said the results of the flu and RSV tests were negative and so she asked the doctor if he wanted a urine specimen collected on the Patient and he said, "sure go ahead". She said the specific physician did not like obtaining urine specimen by pediatric bag, he preferred a catheter "quick in, quick out."
She then asked the other nurse who was present in the emergency center to help holding the Patient while she inserted the Foley catheter, and then she explained to the patient's mother about the procedure she was about to do on the Patient, but the mother did not respond.

She stated "When I went to place the catheter, the baby was crying and wiggling around. It was a hard placement which I partially inserted." She said after a few minutes, the mother told them to stop the procedure and then the doctor came in and told them they did not need to do it because the baby was crying. The physician then spoke to the mother while she the registered nurse went to chart.

She said while charting she received a phone call from someone who identified herself as the Patient's Grandmother. She said the Grandmother did not say nice things to her and that the Grandmother alleged that she abused the Patient.

The Surveyor informed Registered Nurse (H) that she could not locate a documented Physician's order for Foley catheter insertion for collection of urine specimen on the Patient. She said it was a standard practice if the patient is running a temperature and results of the Influenza screen comes back negative then a urine specimen is collected.

When asked by the Surveyor if this was in the facility's policy and procedure. She said she was not sure. The Surveyor also notified her that there was no physician's order for insertion of a Foley catheter for collection of urine specimen.
Registered Nurse (H) did not respond.