F0690

D

Failure to Follow Self-Catheterization Orders and Maintain Proper Catheter Bag Positioning

Charlotte, North Carolina Survey Completed on 01-28-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to follow hospital discharge orders for a resident who required intermittent self-catheterization and failure to maintain proper positioning of an indwelling urinary catheter drainage bag for another resident. One resident was discharged from the hospital with a diagnosis of benign prostatic hyperplasia with urinary obstruction and hospital discharge orders to continue self-catheterization. On admission, a nurse documented that the resident required self-catheterization due to urinary obstruction and reported being informed by the hospital nurse that the resident was self-catheterizing. The nurse stated she notified the DON that the resident needed physician orders and catheter supplies, but there were no physician orders entered in the EMR for self-catheterization, and the DON later reported she did not recall being informed. The Medical Director documented that the resident required self-catheterization and had received education on catheter hygiene, but the admission MDS did not code intermittent catheterization, and the care plan described the resident as usually continent and independent with toileting without reference to self-catheterization.

Subsequently, another nurse documented that the resident became increasingly belligerent and repeatedly requested to self-catheterize due to pain with urination, reporting that he had been self-catheterizing prior to admission. That nurse observed the resident urinating into the toilet and educated him that self-catheterization was not required because he was able to void, and she obtained an order for a urinalysis, which later returned negative. She reported she was unaware the resident required self-catheterization and saw no orders or supplies indicating such a need. The resident’s representative stated the resident had been self-catheterizing for approximately two years due to a urinary blockage requiring surgery, had been hospitalized for a UTI related to reusing catheters, and reported to her about a week after admission that the facility was not providing catheter supplies. The representative obtained approximately 15 catheters from the resident’s urologist and brought them to the resident, and also reported that no catheter supplies were provided to the resident at discharge from the facility.

The deficiency also includes improper management of an indwelling urinary catheter drainage bag for another resident with neuromuscular dysfunction of the bladder and an indwelling catheter order. The resident’s care plan included goals to remain free from complications related to the catheter and interventions such as catheter care every shift and monitoring for UTI. On multiple observations over three consecutive days, the resident was seen in bed with the indwelling catheter connected to a bedside drainage bag that was attached to the bed frame below bladder level, but the bottom of the drainage bag was touching the floor. Nursing assistants and nurses assigned to the resident on those days stated they provided catheter care and were aware that catheter bags should not touch the floor to prevent infection, yet each reported they did not notice the bag in contact with the floor during their shifts. The Infection Preventionist/Staff Development Coordinator and the Corporate Nurse Consultant both stated that urinary catheter drainage bags and valves should be kept off the floor and hung on the bed frame below bladder level to avoid contamination and potential urinary tract infection, confirming that the observed positioning of the drainage bag was inconsistent with expected practice.

The DON later explained that, at the time of the first resident’s admission, the admission nurse position was vacant and the nurse assigned to the resident was responsible for reviewing hospital orders and entering them into the EMR. She stated that when residents are admitted with self-catheterization orders, the usual process is to enter orders into the EMR for the Medical Director to sign, assess the resident’s ability to self-catheterize safely, and provide catheter supplies, but she was unsure why the orders for this resident were overlooked and did not recall being informed by the admitting nurse about the need for self-catheterization and supplies. The Medical Director stated the resident was performing self-catheterization upon admission and acknowledged documenting the need for self-catheterization, but he did not recall whether he signed related orders in the EMR and was not aware of concerns that staff did not know the resident was self-catheterizing or that supplies were not being provided. These combined actions and inactions resulted in the facility not implementing the hospital’s self-catheterization orders for one resident and not maintaining proper catheter drainage bag positioning for another resident, as observed by surveyors.