Failure to Monitor Urinary Catheter Leads to Resident's Decline
Summary
The facility failed to ensure comprehensive monitoring and timely identification of a change in condition for a resident with an indwelling urinary catheter. The resident, who had a history of UTIs, low back pain, hematuria, urinary retention, and heart disease, experienced decreased urine output over three nursing shifts, totaling only 200 ml. Despite this significant decrease, the nursing staff did not conduct a comprehensive assessment or follow up with the STNA staff regarding the resident's urine output. Additionally, the nursing staff failed to notify the physician about the resident's low urine output. The resident's condition deteriorated, and the family requested a transfer to the emergency room. Upon arrival at the hospital, the resident was found to have a firm abdomen, abdominal distension, and pain, with the indwelling catheter draining dark, thick, purulent urine after being replaced. The resident was diagnosed with a UTI and septic shock, which led to hospitalization and subsequent discharge to an inpatient hospice center, where the resident later expired. The cause of death was noted as bacteremia due to septic shock and heart disease. Interviews with facility staff revealed a lack of protocol for handling low or no urinary output and a failure to take appropriate actions such as flushing the catheter or notifying the physician. The staff assumed the family had emptied the catheter bag, and there was no documentation of issues with the catheter or decreased urine output. The facility's policy required monitoring and documentation of urine output and characteristics, but these were not adequately followed, contributing to the resident's decline.
Removal Plan
- The facility identified two charge nurses, LPN #307 and LPN #308 who failed to identify the resident's condition and assess Resident #80 appropriately and timely. LPN #307 and LPN #308 received disciplinary action and education regarding urinary devices, output monitoring, resident assessments, interventions, notification to family and physician, and documentation.
- STNA #315 and STNA #312 were identified as the STNAs involved in Resident #80's care. STNA #315 and STNA #312 were educated on notification of change in resident urine output including amount, color, odor, or complaints of pain from resident.
- RDCS #325 provided education to the DON regarding urinary devices, output monitoring, resident assessments, interventions, notifications to family and physician/nurse practitioner (NP) and documentation. Education was completed to include monitoring of resident with urinary devices related to change in urinary output (decreased ml out, change in characteristics such as color/odor), completing focused urinary assessment (obtaining vital signs, checking abdomen for distention/tenderness, asking resident if any complaints of pain in abdomen, flank, or back, checking condition of catheter drainage for tubing for clot, kinks, sediment, and initiating interventions as needed. The DON educated the two Unit Managers (LPN #301 and #309) on the same above topics. The DON and Unit Managers educated all 26-nursing staff on the above topics.
- The facility identified seven residents (#17, #42, #45, #47, #55, #57, and #62) with urinary devices. The DON assessed the seven residents for signs and symptoms of dehydration, urine output outside of resident baseline parameters, and complaints related to urinary status, and reviewed their medical records. Residents #17, #42, #57, and #62 were stable and no interventions were indicated. Residents #45, #47, and #55 had no urine output documented, and a physician order was obtained to document urine output on each shift. Residents #45, #47, and #55 had sufficient urine output and no other interventions were indicated.
- The DON/Unit Managers educated all 31 STNAs on urinary devices, output monitoring, and notification to the charge nurse of any observed change in resident's baseline status.
- An ad hoc Quality Assurance and Performance Improvement (QAPI) was held to review the findings of Resident #80's change in condition and decreased urine output.
- The DON/designee would review all new physician orders and notes to ensure any change in condition or potential risk of infection were addressed appropriately and notifications were completed. Audits would be completed daily for four weeks and randomly thereafter for a total of four months to ensure appropriate assessment, documentation, and notification.
- The DON/designee would complete audits on all residents with an indwelling urinary catheter weekly for a period of four weeks and randomly thereafter for a total of four months to ensure appropriate assessment, documentation and notification. This audit would include physical assessment of catheter, documentation review of urine output, monitoring of signs and symptoms of infection including urine color being collected. All findings will be reviewed by the QAPI committee with the Medical Director weekly (if necessary) or on a monthly basis.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and a neurogenic bladder had an indwelling catheter ordered with a Stat-lock securement device and shift-by-shift monitoring of urine output. Surveyors observed the resident self-propelling a wheelchair while leaving a stream of apparent urine on the floor and later noted the resident sitting with a very full catheter bag hanging under the wheelchair. During observed catheter care, CNAs emptied the bag and checked the insertion site but did not use a Stat-lock, and one CNA reported they usually emptied catheter bags only at the end of their shift and did not apply a Stat-lock because the resident removed it. A nurse confirmed that all catheterized residents should have a Stat-lock and that supplies were available, while an administrative nurse stated expectations that Stat-lock use follow the care plan and that there was no written catheter care policy, with the facility instead relying on standards of practice.
A resident with a history of obstructive uropathy and a suprapubic catheter returned from a hospital stay with the catheter still in place, but the facility did not obtain new physician orders for catheter care, catheter size, change frequency, or irrigation after readmission. Previous orders for catheter care and monthly catheter changes using a specified 18 Fr/10 cc catheter had expired prior to the hospital transfer. Despite multiple observations of the resident with a leg bag and confirmation by staff that the catheter remained in use, no corresponding catheter-related orders were in the current physician or readmission orders, and the DON acknowledged that appropriate catheter orders had not been obtained.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, neurogenic bladder, and an indwelling Foley catheter experienced a progressive slit on the penis and urine leakage into an incontinent brief due to inadequate catheter monitoring and care. Orders and the care plan required every-shift assessment of the catheter site for redness, irritation, urethral erosion, leakage, and urine characteristics, but nursing documentation showed no reported issues while the penile slit enlarged from a small, non-bleeding area to a beefy red, bleeding wound extending from the meatus down the shaft. During observed care, the resident’s brief was saturated with urine, dressings were wet and non-adherent, and the catheter tubing contained sediment with cloudy, sediment-filled urine in the bag. Staff interviews revealed that some staff had known about the slit for weeks, the assigned nurse had not assessed the penis or recognized leakage despite making rounds, and the NP had not been informed of the worsening condition or catheter leakage, demonstrating failures to monitor, recognize, and report catheter-related complications.
Two residents admitted with indwelling Foley catheters did not have physician orders obtained or implemented for catheter care and management. Nursing documentation and MDS entries showed the presence of Foley catheters, but the EHR lacked orders for catheter maintenance, monitoring, or justification for continued use. One resident was observed with a full urine meter bag that had not been emptied, reported no routine cleansing of the insertion site, and had an undated, loose stabilizer, with family stating they often performed cleaning due to inconsistent staff care. CNAs and RNs confirmed the absence of catheter care orders and related documentation, and the DON verified that expected admission orders for Foley size, justification, irrigation as needed, and twice-daily catheter care were not obtained, in contrast to facility policies.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Follow Catheter Care Standards and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide catheter care in accordance with standards of practice and the resident’s care plan for a resident with an indwelling urinary catheter. The resident had Alzheimer’s disease, CKD stage 3, BPH, obstructive uropathy, neurogenic bladder, weakness, and minimally impaired cognition, and required staff assistance with ADLs due to physical limitations and decreased safety awareness. The care plan directed use of a 16Fr urinary catheter for acute urinary retention with obstruction, use of a Stat-lock device to secure the catheter and reduce tugging, and monitoring of catheter output every shift. The urinary incontinence CAA documented the need for a catheter to address obstructive uropathy and to help prevent skin breakdown and UTI. Despite these directives, the resident was observed self-propelling in a wheelchair with a steady stream of apparent urine on the floor along the hallway, which staff immediately recognized as belonging to this resident. Further observations and interviews showed that catheter care practices were inconsistent with the care plan and standards of practice. During catheter care, the CNAs emptied the catheter bag and assessed the insertion site but the resident did not have a Stat-lock on the thigh to anchor the catheter tubing. A CNA stated they were supposed to empty catheter bags at the end of their shift and that a Stat-lock was not used because the resident “just takes them off.” On another occasion, the resident was observed sitting in the dining room with a full, round catheter bag hanging under the wheelchair, and nursing staff were notified. A nurse stated that CNAs typically empty catheter bags at the end of their shift, while also acknowledging that all catheterized residents should have a Stat-lock and that multiple cases were in stock. The administrative nurse stated her expectation was that the Stat-lock be used unless not tolerated, with such intolerance documented in the care plan, and also reported that the facility had no written catheter care policy and instead followed standards of practice.
Failure to Obtain Physician Orders for Indwelling Urinary Catheter After Readmission
Penalty
Summary
The deficiency involves the facility’s failure to obtain appropriate physician orders for an indwelling urinary catheter for a resident following hospital readmission. The facility’s policy on indwelling urinary catheter care, dated 8/15/25, stated that clinical staff may provide catheter care to help prevent catheter-associated urinary tract infections and prolong the life of the catheter system. The resident, who had diagnoses including repeated falls, anxiety disorder, benign prostatic hyperplasia with lower urinary tract involvement, and a history of lung cancer, had a care plan dated 1/5/26 indicating a history of obstructive uropathy, the need to remain free from catheter trauma, provision of catheter care per routine, and catheter changes per physician order and as needed. Prior physician orders dated 10/27/25 directed staff to provide catheter care, change the suprapubic catheter monthly and as needed, and use an 18 French/10 cc catheter, with documentation of the catheter size inserted; this order ended on 3/25/26. After the resident was sent to the hospital on 3/25/26 due to respiratory concerns and copious mucus and saliva, he returned to the facility on 3/29/26. Review of physician orders and readmission orders dated 3/30/26 showed there were no active orders for catheter care, catheter sizing, catheter change schedule, or catheter irrigation for this resident, despite the continued presence of the catheter. Observations on multiple occasions on 3/30/26 and 3/31/26 documented the resident in bed with a catheter in place connected to a leg bag, and a nurse aide confirmed the presence of the leg bag. During an interview, the DON confirmed that the facility failed to obtain appropriate physician orders for the resident’s urinary catheter as required by facility policy and state regulations.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Monitor and Manage Indwelling Catheter Leading to Worsening Penile Injury and Urine Leakage
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and monitoring for a male resident with an indwelling urinary catheter, resulting in worsening penile injury and leakage of urine into his incontinent brief. The resident had significant medical conditions including hypertension, stage 3 pressure ulcers, neurogenic bladder, obstructive and reflux uropathy, and used an indwelling catheter. His MDS showed severe cognitive impairment, total dependence for toileting, and incontinence of bowel and bladder. His care plan and physician orders required staff to follow catheter-related orders, monitor the catheter site every shift for signs of infection, irritation, urethral erosion, and leakage, and to monitor urine characteristics and report abnormalities to the physician. Surveyor review of prior documentation showed that during an earlier survey, the resident’s penis had a small slit measuring 0.3 cm by 0.1 cm with slight redness, and there was no leg strap or Statlock securing the catheter. CNAs at that time reported they had not previously seen the slit. Despite ongoing orders to monitor for complications each shift, the March MAR entries indicated nurses signed off that there were no issues with the Foley and skin area. However, during a later observation of catheter and incontinent care, the resident’s penis was found to be slit from the meatus down the shaft, with a beefy red color and fresh bleeding. The slit had increased in size to 1.5 cm by 0.5 cm. When the area was wiped, the wipes showed a substantial amount of blood. Staff interviews indicated that the slit had been present and known to some staff for weeks, but they described it as smaller and not bleeding previously. During the same observation, the resident’s brief was saturated with urine, the wetness indicator was not visible, and the wound dressing near the buttock was wet and non-adhesive, with a second dressing soaked. The Foley tubing contained smears of sediment with no urine visible in the tubing, and the Foley bag held cloudy urine with a significant amount of sediment. The nurse assigned to the resident stated he had made rounds twice that day but had not noticed Foley leakage or assessed the penis, and he acknowledged he was aware of the slit from prior orientation but believed it was regular wear and tear from Foley use. He also stated he was not aware of the leakage until he saw the soaked brief and sediment in the tubing and bag, and he did not identify when to obtain an order to flush the catheter. The NP later reported she had not been informed that the slit had worsened, had not been notified of leakage or balloon issues, and had not given the ointment order the nurse described. Other staff, including CNAs, the ADON, DON, and Corporate Nurse, confirmed the slit had been smaller previously, that the Foley had been leaking onto the brief, and that sediment and potential clogging could cause leakage and skin breakdown, but these changes and complications were not consistently recognized, monitored, or reported as required by the resident’s orders and care plan.
Failure to Obtain and Implement Foley Catheter Care Orders
Penalty
Summary
The facility failed to obtain and implement physician orders for the care and management of indwelling Foley catheters for two residents. One resident was admitted with diagnoses including polyneuropathy, acute respiratory failure, and acute pulmonary edema, and both the nursing documentation evaluation and admission MDS documented the presence of an indwelling Foley catheter. However, the medical record contained no physician orders for Foley catheter care and maintenance. On review, the DON confirmed that monitoring and maintenance orders for the Foley catheter were expected but were not present in the record. Another resident, admitted with prostate cancer, benign prostatic hyperplasia, and a recent UTI treated in the hospital where a Foley catheter was placed, was observed with a urine meter bag containing 350 ml of urine that had not been emptied that morning. The resident and family reported that the Foley catheter had not been replaced since admission and that the insertion site was not routinely cleansed, with the family often providing cleaning due to inconsistent staff care. A CNA confirmed the urinary bag was full and should have been emptied at the start of the shift, and noted the catheter stabilizer was undated and loose. Review of the EHR by RNs showed no care or management orders for the indwelling catheter since admission and therefore no documentation of routine catheter care. The DON confirmed that admission orders for Foley size, justification for use, irrigation as needed, and twice-daily catheter care, including cleaning around the insertion site and emptying the bag, had not been obtained or entered, resulting in no documented catheter care in the MAR, contrary to facility policies requiring valid justification and admission assessment with communication to the physician.
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