Failure to Change Indwelling Urinary Catheter as Ordered
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was changed as ordered by the physician for one resident. Observation on 12/17/25 showed Resident #19 in bed with an indwelling urinary catheter. A physician order dated 06/10/25 directed that the catheter be changed monthly on the 9th and as needed, and a quarterly assessment dated 12/04/25 documented that the resident, who had a BIMS score of 15 indicating cognitive intactness, had an indwelling urinary catheter and obstructive uropathy. The care plan revised on 12/04/25 also specified that the catheter was to be changed every month and as needed. The medication administration record for 12/01/25 through 12/17/25 showed the catheter was scheduled to be changed on 12/09/25, but there was no documentation that this was completed. On 12/17/25, the resident reported receiving catheter care but stated the catheter had not been changed in December. LPN #3 stated they believed the hospice nurse had changed the catheter on 12/09/25, while on 12/18/25 the DON confirmed the hospice nurse had not changed it and stated that the charge nurse was responsible for catheter changes and that there was no monitoring in place to ensure catheters were changed as ordered. This deficiency centers on the missed monthly catheter change for Resident #19 despite clear physician orders, care plan directives, and MAR entries, combined with staff misunderstanding about who performed the change and the absence of a monitoring system to verify that indwelling urinary catheters were changed as ordered.
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