F0690

G

Failure to Monitor Catheter Output and Respond to Urinary Retention Leading to Complicated UTI and Sepsis

Mcleansboro, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent urinary tract infections and urinary retention for a resident with an indwelling catheter. The resident had multiple diagnoses including Parkinson’s disease, unspecified dementia, urinary retention, benign prostatic hyperplasia with lower urinary tract symptoms, and chronic kidney disease. The care plan and physician orders required monitoring and documenting intake and output, monitoring for and reporting signs and symptoms of UTI and urinary retention, and changing the 18 Fr coude catheter with 10 cc balloon every 30 days on night shift. The Treatment Administration Record for the entire month of December shows no catheter change, despite the monthly change order. The TAR also documents a progressive decline in daily urinary output from mid-December, with outputs dropping from over 900 ml per day to 200 ml on one day and then no documented urine output on the following day.

Nursing notes show that on 12/08 the RN documented dark amber urine with white sediment in the catheter tubing, with fluids encouraged and a message to the DON, and on 12/09 the urine was still dark yellow, though improved. On 12/16, a note documented that the catheter was not changed at a doctor visit and that there was a new order to change monthly. On 12/19, the DON documented a new order from the urologist to change the catheter to an 18 Fr coude with 10 cc balloon monthly, with a plan to change when supplies were received and a follow-up appointment scheduled. On 12/25, the resident vomited, had a large bowel movement, and was noted to be afebrile in the morning; later that day the resident refused food, took medications with water, had a small amount of amber urine in the catheter bag, and had a low-grade temperature of 99.5 for which Tylenol was given. The LPN caring for the resident on 12/25 reported that there were times when the resident’s urine would get darker and staff would encourage fluids, and she attributed the vomiting to overeating while out with family.

Overnight into 12/26, the DON, who was the nurse on duty, received report that the resident had been sick all day, had not eaten or drunk anything, and had vomited the previous day. She also received report that day shift had flushed/irrigated the catheter without issue, and she did not attempt to irrigate the catheter herself. She did not notify the physician, believing the resident was sick from overeating, and later stated that the resident had no urine output all night; she passed this information to the oncoming day nurse and did not take further action. On the morning of 12/26, an LPN reported being told that the resident had not taken medications, had no urine output, and had not eaten; she assessed the resident, attempted to irrigate the catheter without success, and then notified the physician, who ordered transfer to the emergency department. Another LPN who passed medications that morning stated she did not notify the physician, did not provide catheter care, and did not recall being told there was no urine output. The facility’s catheter care policy required observing urine levels for noticeable increases or decreases and reporting if the level stayed the same or increased rapidly, and required immediate reporting of signs and symptoms of urinary retention or UTI. The output policy required reporting abnormal output within 24 hours. The urology nurse later stated that, given the resident’s diagnosis, prior catheter issues, and decreasing urine output, action should have been taken when decreased output was first noted and when no urine output was observed, including flushing or changing the catheter before complete absence of output.

When the resident arrived at the local hospital emergency department on 12/26, he was lethargic, hypotensive, and had a distended bladder with no drainage in the catheter bag. A bladder scan showed more than 1570 ml of urine. When the existing 18 Fr coude catheter balloon was deflated, brown, foul-smelling urine began flowing around the catheter, and after replacement with an 18 Fr straight-tip Foley catheter, 1850 ml of very malodorous, nearly brown urine with a large amount of sediment was drained. Photos from the hospital showed dark brown, cloudy urine with large amounts of sediment. The ED records documented clinical impressions including hydronephrosis with ureteropelvic junction obstruction, sepsis with acute renal failure and septic shock, and unspecified acute renal failure type, and the resident was transferred to an out-of-state hospital. The out-of-state hospital records documented admission and discharge diagnoses of sepsis, complicated UTI, chronic indwelling catheter, and acute kidney injury on chronic kidney disease stage 3B. The urology nurse reported that, in the urologist’s professional opinion, when no urine output was noticed, something should have been done at that point rather than waiting additional hours, and that with decreasing urine output and an indwelling catheter, the catheter should have been flushed or changed before there was no urine output.