Failure to Follow Physician Orders and Assess Incontinence
Summary
The facility failed to follow the discharge summary physician's order for a resident diagnosed with urinary retention. The resident, who was cognitively intact and required maximum assistance with personal hygiene, returned from the hospital with a diagnosis of urinary retention. The physician's order required bladder scans every six hours while awake and intermittent catheterization for post-void residual urine greater than 600. However, the facility did not have a bladder scanner, and there was no documentation of voiding trials, bladder scans, or intermittent catheterizations in the Treatment Administration Record. The nursing supervisor and unit secretary were unaware of the order, and the care plan did not include revised interventions for urinary retention. Another resident, who was frequently incontinent of bowel and bladder, was not assessed for participation in a bowel and bladder retraining program. The resident was cognitively intact, required substantial assistance for toileting, and was frequently incontinent. Despite being noted as frequently incontinent on the Minimum Data Set assessments, there was no evidence of an evaluation for a bowel and bladder program. The care plan included interventions for incontinence care but did not address retraining. Interviews with staff revealed a lack of documentation and awareness of the resident's incontinence management needs. The facility's policies for managing urinary retention and bowel and bladder programs were not followed. The policy for urinary retention included catheterization as appropriate, but this was not implemented due to the lack of a bladder scanner. The bowel and bladder program policy required assessment for participation in a program for residents with frequent incontinence, but this was not conducted for the resident in question. The deficiencies highlight a failure to adhere to physician orders and facility policies, resulting in inadequate care for residents with urinary and bowel incontinence issues.
Penalty
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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.
A resident with quadriplegia, chronic kidney disease, and a history of UTIs had an indwelling Foley catheter and a care plan directing staff to keep the drainage bag below bladder level, provide catheter care each shift, and monitor and document output. Surveyors repeatedly observed the urine drainage bag, containing a large volume of amber urine with white mucus, lying directly on the floor while an LPN entered the room to administer medications and feed the resident without correcting the bag’s position. Later, despite posted enhanced barrier precautions and available supplies, a CNA wearing only gloves placed a urinal directly on the floor, emptied approximately 1,800 mL from the drainage bag while intermittently placing both the bag and urinal on the floor, left the spigot open on the floor during the process, and failed to clean the spigot tip with alcohol, contrary to facility policy and expected infection control practices.
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.
Improper Foley Catheter Management and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and services for a resident with an indwelling Foley catheter, in accordance with its own urinary catheter care and enhanced barrier precautions policies. The resident had diagnoses including quadriplegia, chronic kidney disease, and depression, was cognitively intact, and had a documented history of urinary tract infections. The care plan and Kardex directed staff to monitor for signs and symptoms of urinary tract infection, position the drainage bag and tubing below the level of the bladder, provide Foley catheter care every shift, and monitor and document Foley output every shift. On multiple observations during one morning, the resident’s urinary drainage bag, containing approximately 1,000 milliliters of amber urine with a large amount of white mucus in the tubing, was seen lying directly on the floor under the bed. An LPN entered the room to administer medications and later to feed the resident breakfast, but did not correct the position of the drainage bag, which remained on the floor at 8:55 AM, 9:10 AM, 10:16 AM, and 11:26 AM. Staff interviewed acknowledged that the drainage bag should not have been on the floor and that it should have been emptied because it was full, particularly given the resident’s propensity for urinary tract infections. Later that morning, despite a sign on the resident’s door indicating the need for enhanced barrier precautions and the availability of supplies, a CNA entered the room wearing only gloves and no gown to empty the urinary drainage bag. The CNA picked the drainage bag up from the floor, placed a clean urinal directly on the floor without a barrier, opened the drainage spigot, and filled the urinal to the top. The CNA then placed the drainage bag with the spigot open back on the floor, emptied the urinal into the toilet, returned the urinal to the floor, and finished emptying the bag into the urinal. The CNA replaced the spigot into the bag holder without cleaning the spigot tip with alcohol and confirmed that 1,800 milliliters had been emptied. Facility nursing leadership and the infection preventionist stated that drainage bags should never be on the floor and that staff were expected to follow enhanced barrier precautions, including gown and glove use, when providing care to residents with Foley catheters.
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