Delayed UTI Treatment and Inadequate Bladder Monitoring Result in Resident Harm
Summary
A deficiency occurred when a resident exhibiting signs and symptoms of a urinary tract infection (UTI) was not treated in a timely manner. The resident, who had a history of multiple medical conditions including metabolic encephalopathy, coronary artery disease, heart failure, hypertension, peripheral vascular disease, thyroid disorder, and osteoporosis, was identified as being at risk for bladder incontinence and was incontinent of bladder. Despite these risk factors, the care plan was not updated beyond the baseline, and there were no interventions documented for bladder incontinence. On a specific date, the resident began to show symptoms of a UTI, including foul-smelling urine, burning during urination, and abdominal pain. The physician was notified, and orders for a urinalysis (UA) with culture and sensitivity (C&S) were placed. Although the urine sample was collected and the order was changed to STAT for immediate pickup, the laboratory results were not reported back to the facility until several days later. During this period, there was no documentation or monitoring of the resident for bladder issues, and no interventions were implemented to address her incontinence or potential urinary retention. The resident did not receive antibiotic treatment for the UTI until six days after the initial symptoms were observed. She was subsequently transferred to the hospital, where it was discovered that she had significant bladder distention with renal pelvictasis. Interviews with facility leadership confirmed that there was a lack of timely intervention and monitoring for bladder issues, and the medical director indicated that nursing staff should have assessed for bladder distention during the period in question. The facility's own policy outlined the need for prompt assessment, monitoring, and treatment of UTIs, which was not followed in this case.
Penalty
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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.
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 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.
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 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 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.
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 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.
Plan Of Correction
F690 Bowel/Bladder Incontinence, Catheter, UTI The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #51 is no longer in the facility. How you will identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken? Residents residing in the facility with indwelling catheters may be affected by the same practice. There are currently 7 residents with catheters in the building. All seven have been assessed on 4-2-26 for symptoms of UTI by the infection preventionist and none have current symptoms of UTI 4-2-26. At the time of assessments, there were no concerns What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee educated the nursing staff on or before 4-9-2026 about the necessary care and treatment of catheter care to prevent catheter-associated urinary tract infections (UTI). This education includes symptoms of UTI. Nurses and STNAs were educated to identify and report a change in a resident's baseline mental, behavioral, or physical status to a nurse and a medical doctor. The nurse would assess the resident's condition based on the information reported. Staff were inserviced on symptoms of UTI. Emergency care for the residents would be provided if appropriate and /or necessary, the physician would be notified if warranted, emergency services would be contacted for transport if warranted, and the party responsible would be notified of a change in mediation or treatment or if the resident was transferred for acute care . Monitor closely for medications ordered. The facility will ensure that the deficient practice does not recur. How the corrective action will be monitored to ensure the deficient practice will not recur. Audits of residents all 7 residents with catheters are being audited weekly by DON/ or designee. If there are more catheters in place they will be added to the number of residents with catheters being audited. The DON/designee will audit for care and signs of infection by observation of the resident, interview with the resident and reviewing progress notes. audit started 4-1-2026 and are ongoing 5xaweek for 4 weeks. Results are supplied to the QAPI team weekly. If concerns are identified, the MD will be notified and staff reeducated in the process of assessing for uti and care and treatment to prevent UTIs.
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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