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Based on record review and interview, the facility failed to evaluate the response to interventions for 1 (Patient #2) of 4 patients reviewed, resulting in the potential for less than optimal outcomes. Findings include:

On 02/28/23, during review of medical record document 'Order Summary' for Pt #2, it was determined that Pt #2 had three medical orders placed at 05:59 on 12/06/22. The three orders were-1. Insert Foley catheter (urine drainage tube); 2. Maintain Foley catheter; 3. Remove Foley catheter. Order #1 was marked 'completed', with a 'stop date and time' of 0611 on 12/07/22. Order #2 was also marked 'completed' with a stop date and time of 0609 on 12/07/22. Order #3 displayed a status of 'Canceled via Patient Discharge', but was not marked completed.

On 02/28/23, during review of medical record document 'ED (Emergency Department) Flowsheet', it was revealed that RN staff R inserted the Foley catheter and collected a urine specimen at 0558 on 12/07/22. The document contained the following information: Urine Characteristics: bloody, clots present. Urine Color: bloody. Urine Voiding: no void. Urinary Intervention: catheter inserted. There were no other entries documenting the removal of the Foley catheter, or further evaluation of the catheter interventions.

Review of discharge instructions for patient #2 titled 'ED Patient Discharge Summary' dated 12/07/22 at 0629 revealed the documents did not contain information regarding care of the catheter or follow-up information.

Review of document 'History of Present Illness' dated 12/07/22 at 0848 revealed "75-year-old male returns via EMS (Emergency Medical Service) after he was discharged from the ED this morning for generalized weakness, when he arrived home he was too weak to get off the EMS stretcher even with two-person assist so his wife requested that he be brought back for admission. He has had progressive severe generalized weakness over the last 24 hours with a negative workup in the ED overnight. For unknown reasons, he had a Foley catheter placed while in the ED which he was discharged home with."

On 02/27/23 at 1027, during tour of the facility Emergency Department (ED), an interview was conducted with ED Medical Director (Staff S). Staff S was queried if patients were sent home with a Foley catheter in place. Staff S stated, "Yes, sometimes with urinary retention, we send the catheter home with the patient." Staff S was next asked, 'Would the patient be instructed how to care for the catheter and when it would be removed?" Staff S stated, "Yes that would be in their discharge instructions and would be instructed verbally also."

On 02/28/23 at 1038, during chart review with Director of ED (Staff E) it was determined that Pt #2 returned to the facility on 12/07/22 'with Foley in place'. Staff E was requested to demonstrate where in the chart it shows the Foley being removed before discharge, and where the patient discharge instructions regarding catheter care were. Staff E stated, "Nothing was documented for either."