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Based on interview and record review, the hospital failed to comply with the Condition of Participation for Nursing Services as evidenced by:

Failure to follow its Policy and procedure (P&P) titled "Bladder Management Protocol" when: (1) nursing staff did not remove the betadine sponge swab after the indwelling urethral catheterization (IUC, known as a foley catheter, a flexible tube inserted into the bladder to drain urine) and (2) there was no physician order for the IUC (Refer to A-398).

The cumulative effect of these deficient practices resulted in the facility's inability to ensure the provision of quality health care. Patient 7 had retained a betadine sponge swab after the indwelling urethral catheterization.

Based on interview and record review, the hospital failed to ensure a Registered Nurse (RN) followed its policy and procedure (P&P) titled, "Bladder Management Protocol" for one of 31 sampled patients (Patient 7), when the RN assigned to insert an indwelling urethral catheter (IUC, known as a foley catheter, a flexible tube inserted into the bladder to drain urine) to Patient 7 failed to follow the urethral catheterization procedure per policy, and there was no physician order for the insertion of the IUC. These failures resulted in Patient 7 having a retained betadine sponge swab inside the female private area after an indwelling urethral catheterization.

FINDINGS:

Review of Patient 7's History and Physical (H&P), dated 3/28/25, the H&P indicated, "Chief Complaint: chest pain. History of Present Illness: 67 year old women with history of obesity (a disorder that involves having too much body fat), TIAs (transient ischemic attack, known as mini stroke), migraines (a headache of varying intensity), HTN (hypertension, high blood pressure), hypercalcemia (high calcium level in the blood), HDL (high density lipoprotein, a good cholesterol), OA (osteoarthritis, a common joint disorder)." The H&P indicated, "Assessment/Plan: 1. NSTEMI (non-ST-segment elevation myocardial infarction, a type of heart attack), admit to cardiac tele, cardiology consultation pending."

Review of Patient 7's Intensive Care Unit (ICU) flowsheets, it indicated, "Urethral indwelling catheter: insert new" on 3/30/25.

Review of Patient 7's physician orders, there was no physician order for the indwelling urethral catheter insertion.

During an interview with the ICU Assistant Manager (AM) on 6/18/25 at 11:08 a.m., she stated RN A inserted a foley catheter on 3/30/25 as preparation for the scheduled surgery, and the betadine sponge swab was found in Patient 7's vaginal opening at the OR (operating room) on 3/31/25. The ICU AM stated RN A stated during her interview that she used the betadine sponge swab to mark the area for the Foley catheter insertion and forgot to remove it after the foley catheter insertion. The ICU AM acknowledged the betadine sponge swab should be used to clean the area prior to insert Foley catheter and be removed and discarded after use.

Review of Patient 7's Nursing Progress Note by the ICU AM dated 4/3/25, the note indicated, "I disclosed to her the inadvertent retention of a foreign body discovered and removed Monday 3/31. I explained the process, rational and intentions for exchanging her Foley catheter on Sunday 3/30 and that the nurse accidentally left a prep swab in her vaginal opening that was then discovered Monday morning when she went to surgery."

Review of Patient 7's Operative Report dated 3/ 3I /25, the report indicated, "Procedures performed: Coronary artery bypass grafting (CABG, a surgical procedure used to improve blood flow to the heart) x5."

During an interview and record review with the Chief Nursing Officer (CNO) on 6/19/25 at 12:40 p.m., the CNO confirmed there was no physician order to insert the IUC for Patient 7. The CNO stated there should be a physician order for the insertion of the IUC.

During an interview with OR RN B on 6/19/25 at 2:47 p.m., she stated Patient 7 was at the OR for CABG procedure on 3/31/25. RN B stated she observed a protruded stick from Patient 7's vaginal opening when Patient 7 was placed in a frog leg position for the CABG procedure. RN B stated she removed the stick which was a betadine sponge swab and assessed Patient 7 for injury.

During an interview with the ICU manager on 6/23/25 at 10:44 a.m. at ICU, she stated the Foley catheter tray contained three betadine sponge swabs to clean the area prior the catheter insertion. The ICU manager acknowledged that the betadine sponge swab should not be used to mark an area for catheterization.

During a telephone interview with RN A on 6/25/25 at 11:08 a.m., she stated she inserted the Foley catheter for Patient 7 on 3/30/25. RN A stated she used the betadine sponge swab to hold some tissues for visualization of the area during the Foley catheterization and forgot to remove the swab. RN A stated she should not have used the betadine sponge swab to hold the tissues. RN A acknowledged that there should be a physician order for the Foley catheterization.

During a review of the hospitals P&P titled, "Bladder Management Protocol" revised 1/19/23 (in effect on incident date), the P&P indicated, "An order from a physician is required for the insertion of an IUC." The P&P included "Indwelling (Foley) Catheter Care" which indicated, "Procedure: Figure 6. Following exposure of the urethral meatus, use an antiseptic solution soaked into cotton balls or oversized cotton-tipped applicators to clean the exposed meatus and surrounding tissues."