Failure to Provide Timely Indwelling Catheter Reinsertion Due to Inaccessible Supplies
Penalty
Summary
The deficiency involved the facility’s failure to ensure timely reinsertion of an indwelling urinary catheter for a resident with a physician’s order to monitor for urinary retention and reinsert the catheter if unable to void. The resident, admitted with diagnoses including myocardial infarction, type 2 diabetes mellitus, and muscle weakness, had an order dated 1/21/2026 to discontinue the Foley catheter and monitor for urinary retention every shift, with instructions to reinsert the catheter if the resident could not urinate. Nursing notes documented that after catheter removal, the resident was being monitored for urinary retention. On the following day, nursing notes indicated the resident was unable to urinate and reported pressure and later pain in the groin and abdomen after multiple attempts to void. The LVN caring for the resident was unable to insert the indwelling catheter as ordered and the resident was subsequently transferred to a general acute care hospital. According to the LVN’s interview, she became aware around 12:30 a.m. that the resident was unable to urinate and was experiencing increasing groin pain, and she knew the physician’s order required catheter reinsertion if the resident could not void. She stated she could not locate the catheter supplies in the facility, asked another nurse for help, and they were still unable to find them. She called the DON for assistance, but the DON did not provide specific instructions on where the supplies were stored, and the LVN reported she had not been oriented to the supply locations. In a separate interview, the DON confirmed receiving a call about the resident’s severe pain and the need for catheter insertion, acknowledged she did not know where the catheter supplies were kept, and stated she later learned they were in a locked nursing supply closet. The facility’s assessment indicated that care for residents requiring intermittent or indwelling urinary catheters was among the commonly provided services, yet the necessary catheter supplies were not accessible or locatable at the time they were needed, resulting in the failure to carry out the physician’s order for timely catheter reinsertion.
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