F0690

G

Failure to Assess Indwelling Catheter and Monitor for UTI in Catheterized Resident

Benton, Illinois Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident admitted with an indwelling urinary catheter was appropriately assessed for timely catheter removal and monitored for urinary complications, including UTI, in accordance with facility policy and physician expectations. The resident was admitted from a hospital with a Foley catheter placed for postoperative urinary retention, with no documented prior history of urinary retention before that hospitalization. The care plan identified an indwelling catheter related to urinary retention and included an approach for a urology consult and reporting UTI symptoms. However, the physician’s initial progress note did not document the presence of the catheter or urinary retention, and there was no documented assessment for catheter removal as soon as possible after admission.

Over the ensuing weeks, there were multiple indications that the catheter was causing discomfort and potential complications, but these did not result in timely diagnostic evaluation. Progress notes document that the resident’s wife reported there was no urinary retention diagnosis and requested discontinuation of the Foley, and that a referral to urology was initiated and later scheduled. Family concerns about catheter-related pain were documented, and nursing staff noted that the resident pulled on the catheter tubing and that he might have transferred germs from his hands to the catheter. A nurse documented sending a message to the NP requesting a urinalysis due to urinary pain, but there is no documentation that an order for a urinalysis was received or that any labs were obtained at the facility prior to the resident’s later hospitalization. The NP later confirmed by phone that the catheter should remain in place until the urology visit, and family was told it could not be removed until then.

Additional clinical changes related to urinary function were documented without corresponding physician notification or diagnostic follow-up. On one occasion, the resident complained of inability to urinate, with abdominal distention and significant sediment in the urine; the LPN replaced the Foley catheter under a standing PRN order, noted good urine return, and did not notify the physician despite the facility administrator’s stated expectation that urinary retention and abdominal distention should be reported. Staff interviews confirmed that there was confusion about why the catheter remained in place, that follow-up urology appointments were not addressed promptly after admission, and that the urology appointment was not pursued until several weeks later. The assistant administrator acknowledged that the urology appointment should have been addressed sooner, and the administrator confirmed that no labs were obtained at the facility before the resident was sent to the hospital with altered mental status, where he was found to have a UTI and hypernatremia. The facility’s catheter care policy required notifying a physician or supervisor if a resident indicated bladder fullness or need to void and observing for signs of UTI or urinary retention, but documentation shows these symptoms occurred without corresponding physician notification or timely diagnostic testing.

The sequence of events culminated in the resident’s decline and hospitalization. Progress notes shortly before transfer describe a change in behavior, decreased speech, inability to feed self, and abnormal movements, leading to transfer to the ER. The hospital history and physical documented that the family reported the resident had been slowly deteriorating over the prior two weeks, with ER workup significant for a positive urine for UTI, elevated sodium, and elevated lactic acid. Interviews with family and staff further indicated that the catheter had remained in place for an extended period, that family repeatedly raised concerns about pain, possible dehydration, and UTI, and that they requested to speak with the physician but were not given that opportunity. The physician later stated that, in general, he would order a urinalysis if he received a report of pain with a urinary catheter and that residents often arrive from the hospital with catheters despite no prior urinary issues, but in this case there was no documentation of such an order or in-house lab work before the resident’s hospitalization.