F0690

J

Failure to Assess, Order, and Care Plan Indwelling Catheter Leading to Septic Shock from UTI

Milwaukee, Wisconsin Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident with urinary incontinence received a comprehensive assessment, physician orders, and care planning for an indwelling urinary catheter. The resident was admitted with severe cognitive impairment, anoxic brain damage, acute and chronic respiratory failure, COPD, heart failure, and was documented on the admission MDS and CAA as always incontinent of bladder and dependent on staff for all ADLs and incontinence care. A care plan was initiated for bladder incontinence related to anoxic brain damage, but there was no documented indication at admission for an indwelling catheter.

Subsequent MDS assessments documented that the resident had an indwelling catheter, and the MAR instructed staff to record Foley output every shift, yet the medical record contained no physician order for the catheter, no documentation of when the catheter was first placed, and no comprehensive care plan addressing indications for use or required catheter care. Nursing notes showed abnormal lab results, including low hemoglobin and hematocrit, and an elevated WBC count initially attributed to recent prednisone use, with repeat labs ordered. Later, the resident was noted to be hypotensive with increased oxygen needs and secretions, and was sent to the hospital.

The hospital discharge summary for that hospitalization documented treatment for septic shock secondary to UTI. When the resident returned from the hospital, there was still no order for the catheter and no care plan directing catheter care and treatment. Months later, a physician order was finally obtained for a 16 French indwelling catheter to promote wound healing, followed by an order to irrigate the Foley catheter twice daily, and only then was a catheter-related care plan developed. The DON later stated that she believed the resident had returned from an earlier hospitalization with a catheter and that nurses did not obtain an order or assess the need for its use, and that she had no explanation for the lack of assessment and orders. The facility’s failures contributed to the resident developing septic shock secondary to UTI due to the indwelling catheter, resulting in a finding of immediate jeopardy beginning on a specified date.

Removal Plan

• All facility nurses re-educated on ensuring that all residents with a foley catheter have an order for the foley catheter along with standard foley catheter orders such as catheter changes, catheter flushing, changing graduate, having a barrier under graduate when draining bag, changing catheter drainage bag, etc.
• Director of Clinical Services (DCS) to assist with providing and explaining re-education to facility nurses.
• DCS assisted with providing 1:1 education with Interdisciplinary team nurses to facilitate and ensure understanding and expectations of processes and policy related to catheter care/orders and to include updating care plans.
• DCS(s) will assist with updating/creating individualized care plans.
• Nursing staff re-educated to complete foley catheter care q shift and prn.
• Nursing staff re-educated about changing out catheter materials biweekly and prn.
• Policy used as reference and guide during training.
• All training to floor staff to be completed by their next working shift.
• Audits will be conducted by DCS or designee on admissions and re-admissions with foley catheters to ensure foley catheter diagnosis and care orders are in place and that foley catheters are care planned appropriately per policy.
• Audits will be conducted by DCS or designee to ensure competency and compliance with catheter care.
• Audits will be conducted to ensure compliance with changing out catheter care materials biweekly.
• DCS or designee will review/audit POC charting Monday through Friday (Monday will include 72 hr review) to review catheter care tasks not completed; ad hoc education will be provided as indicated by DCS or designee for catheter care tasks not completed.
• Audits will be reviewed at the monthly QAPI meeting to determine trends or patterns of concern and/or if further education is needed until substantial compliance has been achieved.