F0690

G

Failure to Provide Ordered Catheter Care, Monitor Urine Output, and Complete Antibiotic Therapy

Urbandale, Iowa Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered catheter care, monitor urinary output as directed, and ensure complete administration of prescribed antibiotics for residents with indwelling urinary catheters. For one resident with multiple sclerosis and neurogenic bladder who used an indwelling catheter, the care plan directed staff to empty the catheter bag every shift and as needed, and a physician’s order required staff to record catheter output every shift. However, review of the Treatment Administration Records (TARs) over several months showed numerous missing entries for catheter output, with output not recorded for a significant number of shifts in December, January, and February despite the standing order to monitor output each shift.

Another resident with obstructive uropathy and an indwelling catheter had multiple hospitalizations related to urinary issues, including sepsis secondary to UTI, enterococcal bacteremia, and complicated UTI. The care plan for this resident identified the presence of an indwelling catheter and directed staff to encourage fluids and check catheter tubing for kinks each shift, but it lacked specific directives for the provision and frequency of catheter care despite an existing physician order for catheter care every shift and as needed. TAR review showed multiple dates over several months where catheter care was not documented as provided, and there was also an order to record urine output that was not consistently followed, with numerous days lacking recorded output. Additionally, although there was an order to change the catheter as needed for leakage, dislodgement, or occlusion, there was no documentation of any catheter change over a several‑month period.

The same resident had an order for Amoxicillin 500 mg PO BID for a total 9‑day course to treat a UTI following hospitalization. The MAR showed missing doses on multiple days, and there was no documentation that the antibiotic was administered for one dose on one day and for all doses on two subsequent days. Pharmacy records from the prior vendor confirmed that only 10 tablets (a 5‑day supply) of Amoxicillin were dispensed, even though the order was for a 9‑day course, and the new pharmacy vendor had no record of dispensing Amoxicillin for this resident. Staff interviews revealed inconsistent practices and instructions regarding reordering medications, use of the E‑kit, and documentation when medications were unavailable, including a CMA’s report that she was told by nursing leadership not to document that a medication was not available or awaiting delivery. The resident ultimately required hospitalization for sepsis secondary to UTI and urinary retention, and later for a complicated UTI, after not receiving the full ordered course of antibiotics and with gaps in ordered catheter care and urine output monitoring.

Staff interviews further showed confusion and inconsistency in following and documenting physician orders, including lab orders for urinalysis and culture, and in using the electronic health record to track orders and results. The NP reported that orders were written with the expectation that facility management would enter and ensure they were carried out, but that there were frequent instances where orders, including antibiotics, were not followed. The DON and nursing staff described differing understandings of when to change catheters and how to document unavailable medications, with some staff stating they were told not to document unavailability. Collectively, these actions and inactions led to missed catheter care, incomplete monitoring of urinary output, and failure to administer a complete antibiotic course as ordered for residents with indwelling catheters and UTIs.

Resident #1 did not receive a full nine-day course of antibiotics to treat a UTI which resulted in a hospitalization.