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F0690
E

Deficient Catheter Care and UTI Prevention

North Hollywood, California Survey Completed on 04-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care and services to residents with urinary catheters, resulting in deficiencies related to catheter management and the prevention of urinary tract infections (UTIs). For one resident with a history of schizoaffective disorder, diabetes, and neuromuscular bladder dysfunction, surveyors observed that the urinary catheter tubing had a loop, which was confirmed by a licensed vocational nurse (LVN). The nurse acknowledged that the tubing should be free from kinks or loops to allow urine to flow freely, as per facility policy and physician orders. Another resident, diagnosed with neuromuscular bladder dysfunction and dementia, was also found to have a urinary catheter tubing with a loop during observation. The LVN present confirmed the improper positioning and stated that staff are required to ensure catheter tubing is free from kinks or loops. The Director of Nursing (DON) reiterated that maintaining unobstructed catheter tubing is an intervention to prevent UTIs, and the facility's policy specifies that catheter and collecting tubes must be kept free from kinking, with the collection bag below the bladder level. A third resident, with diagnoses including UTI, neuromuscular bladder dysfunction, and dementia, was observed to have a urinary catheter connected directly to a leg bag without a securement device or leg strap, and the bag was placed on the resident's thigh. The LVN confirmed that the catheter was not anchored and that leg bags are only to be used when residents are out of bed, unless otherwise ordered. The DON confirmed that the catheter should have been connected to a regular drainage bag and anchored with a leg strap, in accordance with facility policy, to ensure proper urine flow and prevent trauma.

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