F0690

D

Failure to Recognize and Manage Urinary Retention Leading to Delayed Treatment

Redding, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to appropriately recognize and manage urinary retention for one resident, resulting in delayed treatment. The resident had chronic kidney disease and was cognitively intact with a BIMS score of 15, indicating he could make his own decisions. Facility documentation showed that his last recorded urination occurred at 11:32 p.m. on 12/8/25, and there was no further documented urine output for over 14 hours prior to his transfer to the hospital on 12/9/25 at 2:08 p.m. The facility’s own intermittent catheterization policy stated that intermittent catheterization would be used when medically necessary, and nationally recognized resources cited in the report indicated that acute urinary retention can be life-threatening and that treatment involves draining the bladder with a urinary catheter.

Despite this, the SNF/NF to Hospital Transfer Form completed by LN A did not mention that the resident had not urinated for over 14 hours. A subsequent communication note with the physician at 2:39 p.m. documented that the resident had no urine output since the previous day. At the hospital, a urinary catheter was inserted and 2,000 mL of urine was drained, significantly exceeding normal bladder capacity as described in the National Library of Medicine reference. During interviews, the DON acknowledged there was no documentation of urination for over 14 hours, that LN A could have obtained an order for intermittent catheterization but did not realize the resident had not urinated until later, and that the lack of recognition occurred over two shifts. The DON also stated that the facility did not have a urinary retention policy.