Failure to Timely Obtain Urine Culture and Maintain Proper Foley Catheter Bag Positioning
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent UTIs for a resident with an indwelling Foley catheter. The resident had diagnoses including urinary retention, mechanical complication of an indwelling urethral catheter, and type 2 diabetes mellitus with a foot ulcer, and was cognitively intact per an MDS BIMS score of 15. A physician’s order dated 12/22/25 directed staff to collect urine for culture and sensitivity every shift for burning with urination. Nursing notes on 12/23/25 documented the resident’s complaints of bladder pain and dark yellow urine, as well as reports that the resident and family felt staff did not care and that the family frequently requested hospital evaluation for bladder discomfort. Despite the physician’s order, the urine culture was not collected in a timely manner. The DON confirmed that the urine sample for culture was not collected until 12/28/25 at 3:10 a.m., just prior to the resident’s transfer to the hospital, and that there was no endorsement or communication in place to ensure the urine culture would be collected. The DON stated that the nurse who initially received the order no longer worked at the facility and acknowledged that the order should have been followed on 12/22/25. RN A explained that after receiving such an order, it should be entered into the electronic health record and, if not completed, endorsed to the next shift. The case manager later stated that the urine culture should have been done sooner to determine the best antibiotic treatment and to prevent the resident’s emergency department visit, and hospital records showed a positive urinalysis and diagnosis of UTI and cystitis, with IV antibiotics administered and the Foley catheter changed. A separate deficiency was identified related to catheter care technique. During an observation on 2/23/26, the resident’s urine collection bag connected to the Foley catheter was found placed on the floor. A CNA present in the room confirmed that the bag should not be on the floor and stated it should be secured on the bed rail above the floor and below the level of the bladder to prevent infections. Review of the facility’s catheter care policy dated 8/2022 specified that catheter tubing and drainage bags must be kept off the floor and that the drainage bag must be positioned lower than the bladder at all times. This observation showed staff did not follow the facility’s catheter care policy for maintaining proper positioning of the drainage bag.
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