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Based on a review of medical records (MR), facility documents, and interview with facility staff (EMP), it was determined that the facility failed to follow their adopted policy and Medical Staff Rules and Regulations, by failing to obtain a physician order prior to inserting a foley catheter in two of six patients (MR1 and MR28).

The Chambersburg Hospital Subject: Article XXXVIII; Orders, Physician Department: Medical Staff: Classification: Medical Staff Rules and Regulations dated. "39.1 Policy Statement: A. Authorized staff will administer medication or treatment only upon written and signed orders of a practitioner acting within the scope of his or her license, except as provided in this article relating to verbal orders. ... C. The receiving and validating of practitioner's orders is the responsibility of the Registered Nurse. ... 39.2 Procedure: D. Verbal Orders: Authorized staff will accept verbal orders for medication and treatment only in emergency or unusual situations (Department of Health Rule: 107.62), where the urgency of the medical circumstance requires immediate medication or therapeutic treatment (Title 49 Professional and Vocational Standards, Chapter 21). Only the following qualified personnel, with restrictions as noted, who will transcribe the orders in the proper place in the medical record, will take verbal orders: ... 2. A professional nurse ... The verbal order will include the date, time, and full signature of the person taking the order and the responsible practitioner will countersign it within 24 hours. ... Note: ... The nurse will not carry out orders that are illegible or improperly written until the provider rewrites it or the nurse subsequently understands the order. ... 1. Nurses write the verbal orders and read them back to the practitioner for verification of accuracy. 2. Documentation consists of the date, time of the verbal order, practitioner's name, degree, and dictation number, as well as the nurse's signature who took the verbal order. The nurse documents all of this on the physician's order sheet. ... 3. Practitioners are to sign all verbal orders, within twenty-four (24) hours. ... ."



The Chambersburg Hospital Criteria and Protocol for Insertion, Removal and Care of Foley Catheters Department: Patient Services ... Clinical Policy ... February 2016, "Purpose: To establish consistent criteria, protocols, and care of Foley catheters. Policy: It is the policy of Chambersburg Hospital to utilize Foley catheters only for patients that meet this criteria and to remove catheters based on this criteria and protocol. Content: 1. Steps for Meeting the Criteria for Foley Catheter: A. In order for a patient to have a Foley catheter placed, the patient must meet at least one of the following criteria: 1) Acute urinary retention or bladder outlet obstruction (i.e. gross hematuria, hydronephrosis) 2) Patient undergoing surgical repair of genito-urinary tract and or colorectal surgeries. 3) Post-operative less than 24 hours. 4) Critically ill or post-operative patient who has unclear volume status and needs hourly intake and output measurements. 5) Stage 3-4 (perineal/sacral areas) breakdowns related to debilitated, comatose, paralyzed, and incontinent patient. 6) Improve comfort for end-of-life care. 7) Prolonged immobilization due to trauma. 8) Intra-operative monitoring during surgery or large volumes of fluids or diuretics anticipated. 9) Insertion of epidural B. If the patient does not meet any of the criteria, check the physician order for the reason for the catheter. Convenience is not a reason for Foley catheter placement or continuation ... 4. Documentation: ... 2. Document daily reason for Foley catheter. Notify physician if patient does not meet criteria. ... ."



The Chambersburg Hospital ... Critical Care Unit. Standard of Practice. July 2016, "Note: Documentation in Critical Care is based on the following: Assessments and Standard of Practice 1. General: A. Vital Signs: ... 2. Intake and output on all patients ... III. Systems ... Genitourinary System A. General: 1. Monitor output for minimum of 240 milliliters every shift. Call physician if urine output less than 240 milliliters and if any abnormal findings. May scan bladder prior to calling MD to assess for retention. 2. Check color, clarity and odor of urine every shift ... B. Indwelling Urinary Catheter: ... 4. Follow Indwelling Urinary Catheter protocol or if no protocol order assess need for continued use of Indwelling Urinary Catheter. ... ."


1. MR1 dated March 25, 2017, "... History and Physical ... We will monitor electrolytes ... check the magnesium level ... 11:32 Type: Bladder Elimination: Voiding. Method: Urinal. Bladder Pattern: Continent. Output: Urine Amount 375.0 ml ... 14:12 Indwelling Urinary Catheter Order Protocol Order ... Criteria for Indwelling Catheter Insertion Hourly Intake and Output ... Catheter Insert/Removal/Care Insertion ... Urinary Catheter Type/Location: Ureteral Catheter ... Indwelling Catheter Insertion Date ... Mar 25, 2017 ... Urinary Catheter Size 16 French ... Output Urine Amount: 1.0 ml ... Urinary Catheter Patency: Patent/Draining ... Urine Appearance: Clear ... Urine Color: Yellow ... Indwelling Urinary Catheter Care. Catheter Secure: On. No Looping in Cath Tube ... Peri-Care Provided Yes ...
16:24 Type: Nurses Notes: Patient repeatedly stated that he wanted indwelling catheter removed. Indwelling catheter was removed at 1615 ... ."


MR1 dated March 25, 2017, revealed no evidence of a physician order for insertion of the foley catheter at 2:12 PM.


An interview with EMP2 on August 09, 2017, at 3:00 PM, confirmed a physician order was not obtained for the insertion of a foley catheter at 2:12 PM on March 25, 2017.


An interview with EMP2 on August 10, 2017, at 9:30 AM, revealed that PF2 was the nurse who inserted the foley in the patient (MR1) and that PF2 received a verbal order from the physician but did not document the order.


2. MR28 dated July 27, 2017, revealed that the nurse inserted an indwelling foley catheter at 9:13 AM.

MR28 dated July 27, 2017, revealed no documented evidence of a physician order for the insertion of a foley catheter at 9:13 AM.

An interview with EMP2 on August 10, 2017, at approximately 9:30 AM confirmed a physician order (written, verbal or electronic) was not obtained for the insertion of a foley catheter at 9:13 AM on July 27, 2017.