Failure in Catheter Management and Resident Monitoring
Summary
The facility failed to provide necessary and appropriate care and services to prevent complications from urinary catheters for several residents. Resident #1, who had a diagnosis of prostatic hyperplasia, experienced significant issues due to improper catheter management. The nursing staff did not document the free flow of urine to verify the proper positioning of the catheter, and there was a delay in notifying the practitioner about the lack of urine output. This resulted in Resident #1 becoming unresponsive and requiring emergency transfer to an acute care hospital. The report highlights that the facility did not have processes in place to ensure ongoing assessment of residents to prevent complications from urinary catheters. This lack of proper monitoring and documentation was evident in the discrepancies between the Treatment Administration Record (TAR) and the Certified Nursing Assistants' (CNAs) documentation of urine output. The facility's failure to monitor and document urine output as ordered by the physician was also noted for other residents, such as Residents #4, #61, and #8, who had similar issues with catheter management. Additionally, Resident #999, who was incontinent, reported that staff did not respond to her requests for toileting assistance, and her daughter filed a grievance after finding her mother in soiled conditions. The facility's failure to address these issues and ensure proper care and monitoring of residents with catheters and incontinence led to the determination of Immediate Jeopardy, indicating a likelihood of serious harm or injury to the residents.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 no longer resides in the facility. • Residents #4, #5, #8, & #61 had an RN assessment completed. • Resident #999 was provided with care at the time of grievance. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • Current residents had an evaluation completed. • Current residents had an RN assessment completed including a set of vital signs and observation for output and patency. Any changes identified were communicated to the provider and family notification completed. • Facility residents with a score of 13 or greater were interviewed regarding the facility's provision of goods and services. • Facility residents with a score of 12 or less had skin evaluations completed. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Staff Development Coordinator/Designee completed competencies with CNAs on emptying and measuring output for residents with. This competency was conducted using a mannequin with an to simulate the actual emptying of the. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Staff Development Coordinator/Designee completed competencies with licensed nurses on the proper insertion of with return demonstrations. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the requirement of detailed communication during shift to shift report to include any changes in condition, any new physician orders, and review of any new or existing devices including. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education with CNAs on completing the required ADL documentation. • The facility's Staff Development Coordinator/Designee completed education with Nurse Unit Managers and RN Weekend Supervisor on monitoring the completion of ADL documentation. System Change: • Output was added to the MAR to ensure nursing documentation. • CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. • The facility added to the orientation agenda that all newly hired licensed nurses will complete competencies on the proper insertion of with return demonstration prior to providing resident care. • The facility implemented staff huddles led by Nurse Unit Managers to address ADL documentation completion. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with an indwelling catheter and severe cognitive impairment had catheter drainage care observed to be inconsistent with the care plan and facility policy. An RN placed the urine graduate on the floor while emptying the leg bag and did not cleanse the drainage outlet with an alcohol swab, and the resident’s drainage bag was later observed lying directly on the floor instead of being kept in a privacy bag or hung on the bed frame.
Failure to Monitor Catheter-Associated UTI Signs: A resident with dementia, muscle weakness, and protein-calorie malnutrition had a physician order to monitor and report signs of catheter-associated UTI, but staff did not complete the ordered monitoring. The resident was observed with white, milky urine in the catheter tubing and bag on multiple days, the MAR showed the monitoring order was not completed, and the CNO stated the cloudy urine was the resident’s baseline and that no physician notification was documented.
Failure to provide and document condom catheter care for a resident with stroke, contractures, cognitive communication deficit, kidney disease, and chronic sacral ulcers. The resident had a condom catheter placed to help with bladder incontinence and sacral ulcer healing, but the physician orders did not identify the catheter or required care, the care plan only addressed patency, urine output, and skin checks, and the chart lacked catheter care, catheter changes, and skin assessments for an extended period. An incident report showed the catheter became dislodged and caused a 7 cm penile laceration.
Inadequate catheter and perineal care was observed for multiple residents with urinary devices and incontinence needs. A resident with an indwelling catheter had cloudy urine, sediment, bleeding, pain, and an unsecured catheter after staff reportedly pulled on it during care. Other residents were found with urine- and stool-soiled clothing, bedding, and catheter dressings, leaking or dangling urinary tubes, delayed brief changes, and incomplete peri-care that did not include the full frontal perineum, labial folds, urethra, or catheter area.
A resident with a suprapubic indwelling catheter, bladder dysfunction, and a recent UTI was observed in the dining room with the catheter drainage bag hooked to the wheelchair and resting in direct contact with the floor on more than one occasion. Staff, including a CNA, an LPN, and the DON, acknowledged the bag should not have been on the floor, and the facility policy and CDC guidance cited in the report state the drainage bag should be kept below the bladder and not rested on the floor.
Improper Nephrostomy Drainage Positioning: A resident with MS, neurogenic bladder, and a left nephrostomy tube had the drainage bag hung from a wheelchair armrest with tubing positioned above the insertion site, preventing dependent urine drainage. A TMA said this was the usual setup, and the RNCM and DON confirmed the bag and tubing were incorrectly positioned and not allowing urine to drain appropriately.
Improper catheter drainage bag handling and emptying
Penalty
Summary
The facility failed to ensure urinary drainage bags were maintained in a manner that reduced the risk of contamination during catheter care for a resident with an indwelling catheter. The resident had severe cognitive impairment and diagnoses including ichthyosis vulgaris, major depressive disorder, mixed obsessional thoughts and acts, bipolar disorder, candidiasis of skin and nails, and anxiety. The care plan directed staff to ensure the catheter bag was hung on the bed frame and not placed directly on the floor, to use a privacy bag at all times, and to switch between a leg bag during the day and a night bag at night. During observation, an RN emptied the resident’s catheter leg bag by placing the urine graduate directly on the floor before draining the bag into it, and the drainage outlet was closed without being cleansed with an alcohol swab. On another observation, the resident’s catheter drainage bag was lying directly on the floor beside the bed while the resident was in bed with the leg bag secured to the left leg. A NA later changed the resident’s catheter bed bag to a leg bag. The DON stated staff were expected to place the catheter bag into a privacy bag to prevent it from lying on the floor, and the facility policy directed staff to cleanse the outlet with an alcohol swab after draining urine.
Failure to Monitor Catheter-Associated UTI Signs
Penalty
Summary
The facility failed to ensure proper monitoring was conducted to identify potential catheter-associated urinary tract infections for Resident #32, who was admitted and later readmitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. A physician order dated 2/14/25 directed staff to monitor, record, and report signs and symptoms of catheter-associated urinary tract infection, including pain, burning, blood-tinged urine, cloudiness, no output, deepening urine color, increased pulse, increased temperature, urinary frequency, foul-smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. Resident #32 was observed with white, milky urine in the catheter tubing flowing into the catheter bag on 7/7/26, 7/8/26, and 7/9/26. The MAR for 7/1/26 through 7/10/26 documented "No" for completion of the physician order to monitor, record, and report signs and symptoms of catheter-associated urinary tract infection. On 7/10/26 at 10:29 AM, the CNO stated she would not document a change when the urine appeared milky white because this was the resident's baseline, said the monitoring order was not appropriate because cloudiness would be normal for him, and confirmed the record did not include documentation of physician notification regarding urine changes.
Failure to Provide and Document Condom Catheter Care
Penalty
Summary
Appropriate care was not provided for the use of a condom urinary catheter for one resident. The resident was admitted with diagnoses including stroke, contractures, cognitive communication deficit, kidney disease, and chronic sacral ulcers, and a condom catheter was placed on 2/6/26 to help assist in healing a sacral ulcer due to bladder incontinence. The resident's MDS dated 5/5/26 showed the diagnoses remained current. The facility's catheter care policy stated that nursing provides bathing and hygiene, male genitalia are to be cleansed with the foreskin retracted and the meatus wiped, rinsed, patted dry, and the foreskin replaced, and that staff are to document all care and services provided. The resident's current physician orders did not identify the condom catheter or the care required, and the care plan only directed staff to check patency, urinary output, and skin for breakdown. An incident report dated 6/2/26 showed the resident developed a 7 cm laceration of the penis when the condom catheter became dislodged. Clinical documentation did not include catheter care, catheter changes, or skin assessments from 3/28/26 through 5/31/26, when the catheter became dislodged. During interview, the Nursing Administrator confirmed that documentation did not include catheter care, catheter changes, or skin assessments during that period.
Inadequate catheter and perineal care
Penalty
Summary
The facility failed to ensure indwelling urinary catheters and perineal care were provided in a manner intended to prevent urinary tract infection for 4 of 4 residents reviewed for catheter and perineum care. The report describes multiple observations of residents with urinary catheters that were unsecured, soiled, or not cleaned as part of incontinence care, along with delayed or incomplete perineal hygiene after bowel or bladder incontinence episodes. R11, who had diagnoses including rectal cancer, retroperitoneal abscess, colostomy status, diabetes, neuromuscular bladder dysfunction, muscle wasting, and obesity, was observed with cloudy urine, sediment in the catheter tubing, and later cloudy urine mixed with bright red blood after staff reportedly pulled on the catheter during care. The catheter was noted to be unsecured, and the resident reported sharp urethral pain and ongoing discomfort. The catheter remained unsecured over the following days. R10, who had quadriplegia, multiple sclerosis, neuromuscular bladder dysfunction, hydronephrosis, cystostomy status, and a history of UTI, was found with urine-saturated clothing, dressings, and bedding, leaking suprapubic and nephrostomy tubes that were dangling loosely, and fecal matter adhered to the buttocks and skin. R21, who had diabetes, chronic kidney disease, urinary retention, and morbid obesity, waited for incontinence care after a bowel movement, and when care was provided, only the back perineum was cleaned while the frontal perineum and urinary catheter were not cleaned. R15, who had diabetes and morbid obesity, was heavily saturated with urine and bowel movement, and staff cleaned only part of the perineal area, leaving the labial folds, urethra, and inner groin folds uncleaned.
Catheter Bag Resting on Floor
Penalty
Summary
The facility did not ensure appropriate catheter care for a resident with a suprapubic indwelling catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder, presence of urogenital implants, and retention of urine, and the physician ordered the suprapubic catheter to be changed every 4 weeks with urology evaluation every 6th catheter change. The resident’s care plan identified actual, at-risk, and potential complications related to suprapubic catheter use and included use of a dignity bag for the Foley when not in the room. The resident also had been treated for a UTI in 5/2026. Surveyors observed the resident eating lunch in the dining room with the catheter bag hooked on the bottom of the wheelchair and resting in direct contact with the floor. The same condition was observed again while the resident was eating breakfast in the dining room on a later date. Staff were notified each time, and a CNA, an LPN, and the DON acknowledged that the catheter bag should not have been touching the floor. The facility policy stated catheter drainage bags should be covered at all times while in use, and the CDC guidance cited in the report states the collecting bag should be kept below the bladder and not rested on the floor.
Improper Nephrostomy Drainage Positioning
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a left nephrostomy drainage system when the tubing and bag were positioned in a way that did not allow unobstructed dependent drainage of urine. R5’s quarterly MDS identified moderately impaired cognition, need for assistance with ADLs, and diagnoses including multiple sclerosis, neurogenic bladder, and septicemia. The care plan identified altered elimination related to MS, decreased mobility, a left nephrostomy tube related to kidney stones, and Foley catheter placement, and directed staff to monitor for UTI signs and symptoms, provide perineal care, and empty the left nephrostomy as ordered. During observation, R5 was seated in a Broda wheelchair with the nephrostomy drainage bag hanging from the left armrest and the tubing positioned off the side of the wheelchair and above the insertion site. This placement prevented dependent drainage of urine and created the potential for urine backflow. A TMA stated the bag was typically hung that way. The RNCM and DON later observed the system and confirmed the bag and tubing were positioned incorrectly, stating the bag needed to remain below the insertion site to allow urine to flow freely and reduce the risk of UTIs. The facility’s Indwelling Catheter Care Procedure directed staff to provide appropriate care of urinary drainage systems and to place drainage tubing over the resident’s leg and check the tubing for evidence of urine flow.
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