HospitalInspections.org

Based on document review and interview, the facility failed to record documentation to support the need for insertion of a Foley catheter in 1 of 12 (#1-#12) patients reviewed.


This deficient practice had the likelihood to effect all patients of the facility.


Findings included.

On the morning of 10/23/2018 an electronic medical record review patient #1 as actually having documented evidence of Foley catheter in use without a supporting diagnosis for the insertion of the Foley catheter.

Review of the medical record (MR) gave no explanation when or why a Foley catheter was inserted into the bladder of pt #1.

Review of a written complaint submitted by pt #1's daughter indicated the family demanded the insertion of the Foley catheter to reduce their mothers need to ambulate to the bathroom.

The above lack of documentation was confirmed by staff #1 and Staff #3 who were assisting in the electronic MR review.

A review of the policy for F/C use identified the following:

"Does the patient have any of the QUALIFYING INDICATION for indwelling urinary catheter?

1. Hematuria, gross (Large amount of blood in the urine).
2. Obstruction, urinary
3. Urologic surgery/Intra-operative bladder surgery.
4. Decubitus ulcer-open sacral or perineal wound of incontinent patient.
5. I&O (intake and output) critical for patient management.
6. Hemodynamic instability.
7. No Code/comfort care/hospice care.
8. Immobility due to physical constraints (e.g. unstable fracture).
9. Cardiac or Respiratory distress or compromise.

Staff #1 agreed pt #1 did not have a diagnosis of any of the above conditions on 8/7/2018.
There appeared to be no documentation to support the need for or use of an indwelling F/C.

Based on document review and interview, the facility failed to obtain a physician's order for the insertion of a Foley catheter in 1 (#1) of (#1 through #12 patients).

This deficient practice had the likelihood to effect all patients of the facility.


Findings included:


On the morning of 10/23/2018 in the office of the Chief Quality Officer, the electronic medical record (EMR) for patient (Pt/pt) #1 was reviewed with the assistance of staff #1 and staff #3. During the review, pt #1 was identified as having been admitted 8/6/2018, without a Foley Catheter (F/C). On 8/7/2018 pt #1 was identified by the EMR documentation as having 400 cc's urine output via F/C. On 8/8/2018 F/C care was documented as provided to pt #1.

A thorough search of the EMR by staff #1 and staff #3 confirmed there was no physician's order for placement of the indwelling F/C in pt #1's bladder.