F0690

D

Lack of Clinical Indication and Documentation for Indwelling Catheters Leading to Recurrent UTIs

Livonia, Michigan Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure proper diagnosis or clinical indication to support the insertion and continued use of indwelling urinary catheters for three residents, as well as failures in documentation related to catheter necessity and associated UTIs. For one cognitively intact resident, an indwelling catheter was in place despite no documented diagnosis of urinary retention or other genitourinary condition in the diagnosis list. This resident had experienced multiple UTIs confirmed by laboratory results and had received several courses of antibiotics. During interview, the resident reported dissatisfaction with catheter-related care and stated that when she believed something was wrong with the catheter and wanted to go to the hospital, staff refused to call 911 and told her they needed physician permission for transfer; she reported that she had not seen the physician during her stay and felt her rights were violated. When questioned by surveyors, the DON initially acknowledged that urinary retention was not listed as a diagnosis, then left to review the record and shortly afterward had a new diagnosis of urinary retention entered into the electronic record on the same day as the survey, based on a prior urology consult.

A second resident was observed with an indwelling catheter and had a history of UTI with multiple organisms, for which she had received antibiotic therapy. Her son, who was POA, reported that she had recently had a UTI from her catheter and was on antibiotics, and the resident expressed concern about delays in care and the risk of her wounds becoming infected if she remained soiled. Review of her clinical record showed no diagnosis supporting catheter placement, such as urinary retention, bladder obstruction, or neurologic bladder issues. The resident’s care plan documented an indwelling catheter and catheter care from admission, but there were no diagnoses of wounds or genitourinary conditions in the diagnosis list. The DON stated that the catheter was continued because of multiple wounds and that the resident was seen regularly by a wound consultant; however, the wound consult reviewed by surveyors listed multiple pressure ulcers and chronic foot ulcers and documented bowel and bladder incontinence, but did not mention an indwelling catheter as part of the wound treatment plan or as an intervention for wound prevention or healing.

A third resident also had an indwelling catheter in place since admission, with no genitourinary diagnosis documented to support its use. This resident’s record showed a prior episode of flank pain and gross hematuria, with subsequent urinalysis and culture confirming a UTI with multiple organisms, followed by an order for antibiotic therapy. Despite this, there was no diagnosis in the record to justify the ongoing use of an indwelling catheter. During interview, the DON acknowledged that she could not justify the use of urinary catheters for these residents based on the face sheet and diagnosis pages and admitted that diagnoses for catheter use had been missed and were not previously entered. The facility’s own policy on indwelling urinary catheter care and management, which emphasizes that inappropriate or unnecessary catheter use can result in CAUTI and requires documentation of indications for continued catheter use, was not followed, as the records lacked documented indications for catheter placement and continuation for all three residents.

Across all three residents, surveyors confirmed that each had experienced UTIs requiring antibiotic treatment while having indwelling catheters in place, yet their diagnosis lists did not contain conditions supporting catheter necessity. The DON later reported adding diagnoses for some residents based on prior consults and progress notes, but these were not present before the surveyor’s inquiry. The facility policy required review of the necessity of continued catheter use and documentation of indications, maintenance care, assessment findings, and teaching, but the survey findings showed that the indication for catheter use was either absent or only added retroactively, and that the residents’ records did not reflect a clear, clinically supported rationale for the presence of indwelling catheters.