Failure to Monitor and Manage Catheter Care Resulting in Delayed UTI Identification and Harm
Summary
The facility failed to properly assess, monitor, and document the urinary condition of two residents with indwelling catheters, resulting in delayed identification and treatment of urinary tract infections (UTIs). For one resident, who had multiple comorbidities including chronic obstructive pulmonary disease, chronic respiratory failure, and obstructive uropathy, the care plan required monitoring of intake and output, catheter care, and observation for UTI symptoms. However, there was no evidence that urine outputs were monitored or recorded for several months, and staff did not consistently observe or document changes in urine color, consistency, or output. The resident experienced episodes of catheter obstruction, pain, and distention, leading to emergency department transfers. On one occasion, the resident developed septic shock secondary to a catheter-associated UTI, with positive urine and blood cultures for multiple organisms, and required intensive hospital treatment. Another resident with an indwelling catheter due to neurogenic bladder also experienced inadequate monitoring and documentation. The care plan required observation and documentation of intake and output, as well as reporting of UTI symptoms. Despite this, there was no evidence that urine was consistently monitored for color or consistency, and changes in urine appearance were not always reported to a physician. The resident experienced catheter occlusions and thick, milky urine, and laboratory results indicating infection were not promptly communicated to the physician. There was a significant delay in reporting positive urine culture results and initiating antibiotic therapy, despite the medication being available in the facility's automated dispensing system. Interviews with staff, including the DON, LPNs, and medical providers, confirmed lapses in monitoring, documentation, and timely communication of abnormal findings. Facility policy required staff to observe and report signs of infection, but these procedures were not followed. The lack of consistent monitoring, documentation, and timely intervention contributed to actual harm for at least one resident, who developed septic shock and acute kidney injury as a result of a catheter-associated UTI.
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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