Failure to Monitor and Document Urinary Output Leads to Immediate Jeopardy
Summary
The facility failed to ensure proper care and monitoring of residents with indwelling urinary catheters, leading to significant health issues for two residents. One resident, identified as R1, experienced a lack of documented urinary output for two days without physician notification or medical intervention. This resident was subsequently sent to the emergency room and hospitalized with a urinary tract infection (UTI) positive for ESBL and E. coli, as well as cystitis and hydronephrosis. The facility did not notify the physician of the abnormal urinalysis results or follow up with treatment orders, resulting in a repeated hospitalization for the resident due to a UTI and encephalopathy. The facility's failure to document and communicate changes in the resident's condition, such as decreased or absent urinary output, was evident in the case of R1. Despite the facility's policy requiring notification of significant changes in condition, there was no documentation of physician notification from 12/23/24 to 12/28/24. Additionally, the facility did not obtain a urinalysis as ordered by the physician, and the resident's medical chart lacked documentation of urinary output on multiple occasions. This lack of communication and documentation contributed to the resident's deteriorating health condition and subsequent hospitalizations. Another resident, R5, also experienced issues with urinary output documentation. The facility failed to document urine output on several shifts and did not notify the physician of absent or decreased urinary output. This pattern of inadequate monitoring and communication posed a risk to the health and safety of residents with indwelling urinary catheters, leading to the identification of an Immediate Jeopardy situation. The facility's deficiencies in monitoring, documenting, and communicating changes in residents' conditions were significant factors in the adverse health outcomes experienced by the residents.
Removal Plan
- Implement a new process for shift-to-shift communication and medical provider notification and follow-up to ensure physician orders and labs are obtained timely and the physician is notified of results. This includes a practice to exchange information related to urinary output on each shift verbally with a signature from the CNA and the nurse they are giving report to.
- In-service all clinical staff on monitoring outputs for residents with indwelling catheters, which includes completing, monitoring, reporting, and documenting.
- In-service all licensed staff on physician orders and labs being obtained timely and the notification of the physician timely.
- In-service all licensed staff on physician notification of change in urinary status or any change in condition.
- Educate new staff during onboarding and have an in-service sign-off sheet to show the education has been completed.
- Create a binder for agency staff with the educational documents of the same information all of the in-house staff was educated on, and they are to read and sign off on prior to starting their next shift.
- Monitor for compliance to ensure compliance of intervention by auditing.
Penalty
Resources
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Two residents did not receive timely bladder-related care, including delayed assessment and treatment of UTI symptoms and prolonged response to incontinence needs. One resident with cognitive and physical impairments, fully dependent for ADLs and incontinent of bowel and bladder, exhibited agitation, hallucinations, altered mental status, and dysuria, yet a physician-ordered urine dip was not obtained as scheduled, and a urine specimen was not collected and sent for testing until six days after symptoms were noted, despite later confirmation by an RN and the resident’s family that UTI signs were present. Another resident with intact cognition, a colostomy, spinal stenosis, and urinary incontinence, care planned for assisted toileting and frequent brief changes, activated the call light due to being wet but waited 41 minutes before a CNA responded; the brief was found full of urine, and both the CNA and DON acknowledged the delay was excessive.
A resident with severe cognitive impairment and an indwelling catheter had documented purulent and greenish drainage, pain with urination, and UA results consistent with UTI, followed by a culture showing heavy pseudomonas growth and a handwritten Bactrim DS order that was never administered per the MAR. Over the following weeks, provider notes did not address urinary status, and no repeat UAs were obtained. Later, the resident complained of inability to void, had no catheter output, a distended hard abdomen, green foul-smelling penile discharge, and dark, odorous urine after catheter change, yet there was no documentation of physician notification or UTI-focused lab orders at that time. The resident was subsequently hospitalized and diagnosed with UTI, while facility policies required monitoring urine output and reporting changes in condition to the physician.
A resident with quadriplegia and neurogenic bladder, dependent on staff for toileting, had a care plan and physician order for a 12F/10 cc Mitrofanoff catheter to be changed monthly. Record review showed no documented catheter change for the month in question, and progress notes did not mention any catheter changes. During observation, an LPN verified that the resident instead had a 14F/10 cc catheter in place and was unable to state how long the incorrect catheter had been used.
Surveyors found that staff failed to provide timely and complete incontinence care for two residents. One resident with paraplegia and stage IV pressure ulcers had a soiled brief removed, but the CNA did not cleanse urine from the anterior perineum before applying a new brief. Another resident in a persistent vegetative state, fully dependent and incontinent, was left on the back for several hours without incontinence checks; an LPN discovered the resident heavily soiled with urine while providing G-tube care but did not address the incontinence, and the resident was not changed until later by CNAs. Staff reported residents were to be checked and changed every two hours, and the DON stated there was no formal incontinence care policy, with the task treated as standard practice.
A resident with neuromuscular bladder dysfunction and an indwelling urinary catheter, who depended on staff for toileting and mobility, was observed receiving catheter care from a CNA. After emptying the urinary drainage bag into a urinal, the CNA reinserted the drainage tubing tip into the storage sleeve without cleaning it with an alcohol pad, contrary to facility policy and the catheter care skills checklist. In interviews, the CNA acknowledged not using an alcohol pad, and an RN confirmed that the tubing end should be wiped with alcohol before reinsertion.
A resident with dementia, neuromuscular bladder dysfunction, and a Foley catheter, who was fully dependent on staff for ADLs and incontinent care, was not checked or changed in accordance with the care plan and facility policy. On two separate mornings, surveyors observed the resident in bed with a strong stool odor. A CNA acknowledged the resident had not been checked for several hours despite a stated expectation of checks every two to three hours and indicated she would delay changing the resident until after breakfast. The facility’s incontinence care policy required proper care to prevent skin breakdown, infection, and to promote dignity, but this was not followed.
Delayed UTI Management and Incontinence Care Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and treatment for a resident with signs and symptoms of a urinary tract infection (UTI). One resident with cognitive impairment, severe physical impairment, and total dependence for ADLs was care planned for bowel and bladder incontinence with interventions to keep the skin clean and dry. Progress notes documented that the resident exhibited behavioral changes, including agitation, hallucinations, altered mental status, and complaints of burning pain with urination. A physician order was obtained to perform a urine dip and notify the physician, but the urine dip ordered on 12/16/25 was not obtained as scheduled. Subsequent documentation showed that the urine dip was not actually completed until several days later, when the resident was straight catheterized and a urine dip revealed positive nitrites, leukocytes, and blood, consistent with a UTI. An antibiotic was then started, and a UA with culture and sensitivity was ordered. The unit manager RN later confirmed that the resident had signs and symptoms of a UTI on 12/15/25 and that the urine sample was not collected and sent out until six days later, stating that the specimen should have been collected and sent immediately. The resident’s daughter reported that in December the resident had UTI symptoms and was not started on an antibiotic for six days, and that staff had told her the resident was at baseline and did not have a UTI. The deficiency also includes failure to provide timely incontinence care for another resident with intact cognition, a colostomy, spinal stenosis, weakness, and inability to control bowel or bladder. This resident’s care plan called for staff assistance with toileting, frequent checking and changing of briefs, and provision of toileting hygiene with brief changes. Surveyors observed the resident’s call light on and, upon interview, the resident stated he had turned it on because he was wet and needed changing and that staff did not always respond timely. The call light remained on for 41 minutes before a CNA entered to provide incontinence care, at which time the resident’s brief was full of urine. The CNA and the DON both acknowledged that 41 minutes was too long for a call light to remain unanswered for a resident needing staff assistance.
Failure to Manage Catheter-Associated UTI and Notify Physician for Change in Urinary Status
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and treatment for a resident with an indwelling urinary catheter who exhibited signs and symptoms of a urinary tract infection (UTI). The resident had multiple medical diagnoses including diabetes mellitus, Down’s syndrome, Hirschsprung’s disease, and obstructive and reflux uropathy, and was severely cognitively impaired and dependent on staff for ADLs. The resident had an order for a 16 French catheter to straight drain with catheter care every shift and as needed. On 04/09/25, nursing documentation noted purulent drainage from the catheter site, a small amount of grey-green drainage from the catheter, and the resident’s complaint of pain with urination. A UA with reflex culture was ordered on 04/11/25, and the UA showed yellow, turbid urine with positive hemoglobin, nitrates, WBCs, and RBCs, and a urine culture was ordered. On 04/14/25, the physician progress note documented the resident was seen for a UA concerning for UTI and that an antibiotic was being started, with no other complaints. The catheter was changed on 04/16/25 per the monthly schedule. The 04/16/25 urine culture showed greater than 100,000 pseudomonas, and the paper copy of the culture had a handwritten order for Bactrim DS twice daily for seven days with an illegible signature. However, the April 2025 MAR contained no documentation that Bactrim or any other antibiotic was administered, and subsequent physician notes on 04/22/25 and 04/30/25 did not address urinary status. The NP monthly note dated 05/19/25 also did not address urinary status. The MDS nurse later confirmed that Bactrim was not administered as ordered and that no repeat UAs were obtained in April or May 2025. On 05/23/25 at 5:30 A.M., a nurse’s note documented that the resident yelled out that he could not urinate, the catheter had no output, the abdomen was distended and hard, and a CNA reported no urine output for the entire shift. The nurse removed the old Foley catheter, observed a large amount of green foul-smelling discharge from the penis, inserted a new catheter using sterile technique, and obtained 500 cc of dark, odorous urine, with a culture collected. There was no documentation that the physician was notified of these UTI symptoms or decreased urinary output, and the only new order on 05/23/25 was for a genital culture, which later showed normal flora, with no orders for UA or other labs related to UTI symptoms. The record also lacked documentation of physician notification or the reason for the resident’s transfer to the hospital on 05/28/25, where the resident was diagnosed with UTI, atypical pneumonia, and GERD and prescribed Levofloxacin. Facility policies on urinary catheter care and change of condition required observation and reporting of changes in urine output and resident condition to a nurse and physician, but the documented care and communication did not reflect adherence to these policies.
Incorrect Urinary Catheter Size Used Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident with an indwelling urinary catheter received the correct catheter size as ordered by the physician and outlined in the care plan. The resident was admitted with diagnoses including quadriplegia and neuromuscular dysfunction of the bladder, and had intact cognition but required total staff assistance for bed mobility, transfers, and toileting. The resident’s care plan specified a Mitrofanoff catheter 12 French (F) with a 10 cubic centimeter (cc) balloon to be changed every 30 days, and the physician’s order directed that this 12F/10 cc Mitrofanoff catheter be changed on the 28th of each month. Review of the medical record showed no documentation on the medication administration record of any urinary catheter change for the resident in the month of March prior to the observation of the incorrect catheter. Progress notes from 03/01/25 to 03/22/25 were also silent regarding any catheter changes. During an observation with an LPN on 03/17/26, the resident was found to have a 14F/10 cc catheter in place instead of the ordered 12F/10 cc catheter. The LPN confirmed the catheter size was incorrect and stated that the catheter should be 12F/10 cc, but did not know how long the 14F/10 cc catheter had been in place.
Failure to Provide Timely and Complete Incontinence Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and effective incontinence care to two residents. One resident with paraplegia, chronic osteomyelitis, two stage IV pressure ulcers, urinary incontinence, and dependence on staff for ADLs had a care plan that included monitoring for UTI signs and providing incontinence care as needed. During observed incontinence care, a CNA removed a urine- and bowel-movement–soiled brief, cleansed only the fecal matter, applied a new brief, and did not cleanse the resident’s anterior perineum of urine. The CNA confirmed in interview that the urine was not cleansed from the anterior perineum during this incontinence care episode. Another resident, in a persistent vegetative state, severely cognitively impaired, incontinent of bowel and bladder, dependent for all ADLs, and at risk for pressure ulcer development, had a care plan intervention to provide incontinence care as needed. Two CNAs were observed to perform incontinence care and reposition the resident, after which the resident remained on his back for several hours. From the time of that care until late morning, no staff were observed checking the resident for incontinence needs. When an LPN later entered the room and exposed the G-tube site, the resident was found to be heavily soiled with urine in the brief, but the LPN did not address the incontinence at that time and proceeded only with G-tube care. The resident was not changed until nearly an hour later, when two CNAs entered, found the resident heavily soiled with urine, and then provided cleansing and repositioning. Staff interviews indicated residents were to be checked, changed, and repositioned every two hours, and the DON stated there was no written policy, with incontinence care considered a standard practice task.
Failure to Follow Facility Procedure for Cleaning Urinary Drainage Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate urinary catheter care in accordance with its own policy and skills checklist. A resident with neuromuscular dysfunction of the bladder, intact cognition, and dependence on staff for toileting, transfers, and bed mobility was admitted with an indwelling urinary catheter. The resident’s care plan specified catheter care every shift, changing the catheter bag as needed, and changing the catheter per physician orders. The quarterly MDS documented ongoing urinary catheter use. During an observation, a CNA performed catheter care and then proceeded to empty the resident’s urinary drainage bag into a urinal after performing hand hygiene and donning gloves. After draining the bag, the CNA reinserted the tip of the drainage tubing back into the storage sleeve on the urinary drainage bag without using an alcohol pad to clean the end of the tubing. In a subsequent interview, the CNA acknowledged not using an alcohol pad, and an RN confirmed that staff should clean the end of the drainage tubing with an alcohol pad before reinserting it into the storage sleeve. Review of the facility’s catheter care and urinary output measurement skills checklist from 2009 showed that staff were required to close the drainage outlet, wipe it with an alcohol pad, and then reinsert it into the catheter bag without contaminating it. This failure was identified as an incidental finding during a complaint investigation.
Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to a resident who was always incontinent of bowel and had a Foley catheter in place. The resident had diagnoses including unspecified dementia with psychotic disturbance, neuromuscular dysfunction of the bladder, and pneumonitis due to inhalation of food and vomit, and was documented as having impaired cognition and being dependent on staff for ADLs and incontinence care. The care plan directed staff to monitor and document for signs and symptoms of UTI, provide staff intervention for incontinent episodes, and reposition the resident every two hours and as needed due to risk for skin breakdown. On one observed date at 9:59 A.M., the resident was found lying in bed with a strong odor of stool. At 10:30 A.M., a CNA reported that the resident had not been checked since 6:00 A.M., acknowledged that the resident should have been checked every two to three hours, and confirmed the resident had an odor of stool. On another observed date at 8:42 A.M., the resident was again observed lying in bed with a strong odor of stool, and the same CNA confirmed the odor and stated she would change the resident after feeding her breakfast. The facility’s incontinence care policy required proper incontinence care for all incontinent residents to help prevent skin breakdown, the spread of infection, and to promote dignity, but the observed care did not align with these expectations.
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