Failure to Assess Ongoing Need for Indwelling Foley Catheter
Penalty
Summary
The deficiency involves the facility’s failure to assess and act on the continued need for an indwelling Foley catheter for one resident following a urology visit. The resident was originally admitted with diagnoses including essential hypertension and had a history of renal stones and a ureteral stent. A urology After Visit Summary dated 6/25/25 documented instructions that it was acceptable to remove the Foley catheter and to replace it only if the resident was unable to void after six hours or had a post-void residual greater than 250. Despite these written instructions, the catheter remained in place for months, and there is no documentation that facility providers assessed whether the catheter was still necessary after the June 2025 appointment. During the months following the urology visit, the resident repeatedly experienced problems with the catheter, including leaking and pain. Progress notes show that on 9/29/25 the resident complained of leaking around the Foley, with the bed noted to be wet with urine; the nurse removed the old Foley, encountered resistance and a blood clot during reinsertion, and then placed a new catheter, after which the resident reported feeling better. On 10/1/25, the resident again reported leaking from the insertion site, and the nurse flushed the catheter and adjusted the balloon to stop the leaking. On 10/6/25, the resident again reported leaking; the nurse deflated and repositioned the balloon, flushed the line, and observed all saline leaking from the insertion site. Multiple attempts by two nurses to reinsert a new catheter were unsuccessful due to resistance, and the resident was then allowed to void without a catheter, using briefs while staff monitored output and possible retention. Interviews confirmed that key staff and providers did not assess the ongoing need for the catheter after the June 2025 urology visit. The resident reported that he had the Foley catheter for months after the appointment, had asked staff several times to see if he still needed it, and felt the facility did not act promptly, causing frustration and pain from frequent leaking and discomfort. The Unit Manager stated she was unsure whether the catheter was supposed to be removed after the June visit, acknowledged that the urology note indicated removal was acceptable, and could not recall why the facility had not removed it or whether facility providers had assessed the need for continuation. The Medical Director reported he had not assessed the resident to determine if the Foley was still needed and did not see the resident often enough to comment on why it remained in place. The PA believed the resident had urinary retention, had not assessed whether the catheter could be removed, and was unaware that the catheter had already been discontinued until informed during the interview.
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