F0684

G

Failure to Follow Urology Orders for Indwelling Catheter Care Leading to UTI and Sepsis

Belleville, Illinois Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and provide appropriate care for a resident with an indwelling urinary catheter, resulting in a urinary tract infection with sepsis requiring hospitalization and IV antibiotics. The resident had multiple significant diagnoses, including cerebral infarction, osteomyelitis, diabetes mellitus, peripheral vascular disease, chronic kidney disease, congestive heart failure, diabetic polyneuropathy, a stage 4 pressure ulcer, and a neurogenic bladder managed with an indwelling urinary catheter. The resident was cognitively intact and dependent on staff for mobility. A urology consult on 7/8/25 documented that the resident’s catheter had not been changed at the facility and that the resident reported the facility could change it with an order. The urologist assessed the resident and ordered an indwelling urinary catheter change that day and monthly thereafter, indefinitely, with PRN changes if the catheter was not draining.

Following the urology visit, a facility progress note on 7/8/25 documented that the resident returned from the appointment with a new order to change the indwelling urinary catheter that day and monthly thereafter. The Treatment Administration Records (TARs) for October and November 2025 showed a standing order to change the catheter monthly on night shift starting on the 8th of each month, but there was no documentation that the catheter was changed on 10/8/25 or 11/8/25 as ordered. A progress note on 10/9/25 recorded that the resident had bleeding from the penis and that the monthly catheter change, due the previous day, was then performed. Subsequent notes documented a urinalysis collected on 10/20/25 and initiation of nitrofurantoin for a UTI on 10/23/25, as well as continuation of IM antibiotics related to UTI on 11/4/25. The DON later acknowledged that the catheter was not changed as ordered in October or November 2025 and could not produce any order or physician notification changing the monthly order to PRN only.

On 12/3/25, a progress note described the resident as shaky with elevated temperature and tachycardia, with a blood sugar of 319, followed by emesis and transfer to the hospital. The hospital history and physical documented that the resident reported noticing sediment in his urine, stated his catheter had been changed three days prior but that it had been over 40 days since the previous change, and that he had been telling facility staff about it. The hospital documented that the resident met sepsis criteria with a markedly elevated white blood cell count, fever, tachycardia, increased respiratory rate, and significant pyuria and hematuria on urinalysis. The resident later stated that prior to moving to the facility his catheter tubing and bag had been changed monthly and he did not get UTIs, and that at the facility his catheter bag and tubing were not changed monthly despite his belief that there was a physician’s order to do so. He reported being hospitalized twice in recent months for severe UTIs requiring IV antibiotics and expressed frustration that staff were not following physician orders, describing the situation as neglect. The facility’s catheterization policy addressed changing catheters PRN when not draining but did not address following physician orders for catheter changes, and the DON stated the facility does not do indefinite orders and that specialist orders were considered no longer in effect once a resident goes to the hospital, despite no documentation of revised orders for this resident.

The resident also reported that staff did not clean around his catheter site daily and that this care was rarely performed. A wound care nurse stated that the catheter was ordered to be changed on night shift and that if it was not signed off, it was not done, and further stated that when the resident was readmitted from the hospital, the nurse should have restarted the previous orders for consistency unless otherwise specified. A hospital case manager confirmed that urology had ordered monthly catheter changes during a July 2025 hospitalization and that during the December 2025 hospitalization the resident again reported that the facility had not been changing his catheter monthly as ordered, leading physicians to again order monthly catheter changes. The administrator acknowledged that if a catheter change was not documented on the TAR, she assumed it was not completed. Overall, the documented failures included not completing monthly catheter changes as ordered, not following the urologist’s written orders, not verifying or reinstating specialist and hospital discharge orders, and not consistently performing catheter site care, culminating in the resident developing a UTI with sepsis requiring hospitalization and IV antibiotics.