Failure to Assess, Order, and Care Plan Indwelling Catheter Leading to Septic Shock from UTI
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Improper Foley Catheter Care During Incontinent Care: A resident with dementia and neurogenic bladder had an indwelling catheter, but a CNA did not secure the catheter tubing while providing incontinent/catheter care. The DON and ADM stated the tubing should be secured during care, and the CNA acknowledged she was not aware she had failed to do so despite prior training.
Indwelling catheter care was not provided as needed for a resident with Foley tubing that had cream-colored sediment along the length of the tubing on repeated observations. The resident had orders for Foley care every shift and irrigation for blockage, increased sediment, or decreased output, but staff and hospice interviews showed the tubing remained unchanged and there was no formal order for routine tubing changes, only PRN changes based on clinical findings.
A resident with an indwelling Foley catheter, dementia, and recent admission diagnoses including cancer and a pelvic fracture was observed without the ordered leg strap/securement device in place. The care plan did not reflect the need for securement, and staff interviews confirmed the tubing should have been secured and checked each shift; the ADM also stated there was no catheter care policy.
Failure to Document and Manage External Catheter Urinary Wicking System: A resident who used an external male catheter with a urine collection system had no physician order, no care plan details for setup or reapplication, and no documentation for changes. The resident said he needed help with the system and kept supplies in his room, while the DON stated the hospice nurse applied it weekly and acknowledged there was no policy or documentation for changes. Containers of urine were observed in the room, including one full of dark yellow urine, and the bag was later not found during brief care.
Delayed Incontinence Care: A resident with bowel and bladder incontinence, impaired mobility, and dependence on staff for ADLs was observed wet in bed and asking to be changed and cleaned up. An LPN checked the brief, confirmed it was wet, but left the room without providing care and was later observed at a med cart during another staff member’s med pass. The resident stated she had last been changed the night before and that it had been a long time.
Delayed Toileting and Incontinence Care: A resident with intact cognition, urinary and bowel incontinence, and max assist needs was left in a wet brief and later found sitting on a urine-soaked wheelchair cushion. Staff reported the resident had called for bathroom help during lunch, but assistance was delayed until after dining room duties, and the DON stated residents should be changed every 2 hours and assisted before meals when they request toileting.
Improper Foley Catheter Care During Incontinent Care
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate catheter care and services to prevent urinary tract infections and to restore continence to the extent possible. Resident #18 was an [AGE]-year-old male admitted with dementia, neuromuscular dysfunction of the bladder, heart failure, hypertension, and difficulty walking. His quarterly MDS identified that he had an indwelling catheter and a diagnosis of neurogenic bladder, and his care plan included a focus area for an indwelling catheter related to neurogenic bladder. During observation, CNA A provided incontinent care and catheter care to Resident #18 but held the tip of the penis with the left hand while cleaning the catheter tubing with the right hand and did not secure the tubing during the care. In interviews, the DON and ADM stated the tubing should be secured during catheter care and that staff had been trained in proper catheter care. CNA A stated she was not aware she had failed to secure the catheter tube and described the proper process as securing the tubing at the tip of the penis and wiping downward. The facility policy on catheter care stated the purpose was to prevent catheter-associated urinary tract infections and directed staff to maintain the position of the nondominant hand and cleanse the catheter from the insertion site outward.
Indwelling Catheter Care Not Provided as Needed
Penalty
Summary
Failure to provide treatment and services for the care of a resident with an indwelling urinary catheter was identified for one of five residents reviewed. During observation of the resident on 08/09/2026, Foley tubing had cream-colored sediment along the length of the tubing, and the same sediment was still present and unchanged during a second observation on 08/11/2026. The resident’s record showed physician orders for Foley care every shift and for irrigation with 60 cc normal saline for blockage, increased sediment, or decreased output every 6 hours as needed, with notification of the physician for any abnormal observation from baseline. Staff interviews showed that the CNA would notify the nurse if something was wrong with the Foley when emptying it, and the hospice director stated the hospice aide documented care and would notify the RN and floor nurse if there were new findings or resident complaints. The ADON/Infection Control Nurse stated the Foley catheter tubing should be changed based on how it looked, but there was no formal order for routine tubing changes and it was only PRN. The DON stated a PRN Foley change would be needed if there was leakage, blockage, or sediment that could not be flushed out. The facility policy stated routine fixed-interval catheter changes are not recommended and that residents should be observed routinely for complications and new complications reported to the provider as indicated.
Failure to Secure Foley Catheter Tubing
Penalty
Summary
Resident #58, an [AGE]-year-old female newly admitted with diagnoses including secondary malignant neoplasm, fracture of the superior rim of the left pubis, and dementia, had an indwelling Foley catheter ordered on 08/06/2026. Her care plan identified the indwelling Foley catheter as a problem and included a goal that she remain free from catheter-related trauma, but it did not reflect the need for a leg strap to secure the tubing. The order summary included an order to check the indwelling urinary catheter securement device every shift and to use a leg strap to secure the Foley in place. During observation of catheter care, Resident #58 had an indwelling urinary catheter and did not have a leg strap or securement device in place. CNA B stated the tubing should have been secured and that the purpose of securing it was to prevent pulling on the tubing, which could cause it to come out and require reinsertion. LVN D stated there was an order to check the securement device every shift but did not know why it was not in place. The ADM stated she did not have a policy for catheter care, and the DON stated it was her expectation that urinary catheter tubing be secured and that CNAs should notify the nurse if a securement device needs to be replaced.
Failure to Document and Manage External Catheter Urinary Wicking System
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for one resident who used an external male catheter with a urine collection system. The resident was admitted with diagnoses including anxiety disorder, chronic pain syndrome, scoliosis, and end stage heart failure. His admission telephone order and physician orders did not include any order or instructions for the external catheter urinary wicking system, and his comprehensive care plan did not address the system, including who would reapply it, empty the canister, or how often those tasks were needed. The care plan instead addressed bladder incontinence with incontinent care every 2 hours and moisture barrier application after each episode. During interview and observation, the resident stated he used the external catheter urinary wicking system, paid for the supplies himself, and needed assistance with setup and reapplication as needed. He pointed to boxes of supplies in his room, and two urine collection containers were observed on the floor next to the bed, with one container full of dark yellow urine. The DON stated the hospice nurse applied the system weekly on Mondays and acknowledged there was no documentation for it being changed and no policy for the external catheter urinary wicking system. Later observation showed the bag had been off since the prior day, and when the DON and Regional nurse were changing the resident's brief, the bag was not seen in the brief or in the bed.
Delayed Incontinence Care
Penalty
Summary
Timely incontinence care was not provided for Resident #13. The resident was admitted with diagnoses including acute kidney failure, acute chronic diastolic congestive heart failure, and peripheral vascular disease. Her care plan documented impaired mobility, bowel and bladder incontinence, dependence on staff for ADLs, and interventions to assist with toileting needs throughout the day and to check and change her as needed. The MDS showed a BIMS score of 15/15, and the resident was impaired in both upper and lower extremities and dependent on staff for ADLs. During an observation and interview on 07/22/26 at 7:37 A.M., Resident #13 was in bed pointing to her brief and stated she was wet and needed to be changed and cleaned up. She said she had last been changed the night before and that it had been a long time. At 7:39 A.M., an LPN observed in the room checked the brief, confirmed the resident was wet, fastened the brief back together, pulled up the covers, washed her hands, and left the room stating she would be back. The LPN was then observed standing next to a medication cart watching a medication pass by another surveyor and did not change the resident at that time. The facility policy titled Incontinence Care stated the facility had a policy to ensure residents who were incontinent of bowel and/or bladder received appropriate treatment and services.
Delayed Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide timely toileting assistance and incontinence care for Resident #6, who had a BIMS score of 13 indicating intact cognition and required maximum assistance for toileting hygiene and toileting transfers. Resident #6 had occasional urinary incontinence and frequent bowel incontinence, with diagnoses including a left femur fracture, COPD, bipolar disorder, anxiety, and dementia. The care plan identified bladder incontinence, self-care deficits, impaired balance during transitions, and incontinence, with interventions calling for two staff members for transfers. During observation, Resident #6 was found sitting on the edge of the bed while the resident representative and Staff A were present. The resident representative asked whether the wheelchair cushion was wet and removed it, showing urine wetness soaked through to the bottom of the cushion; the resident representative also stated the wheelchair felt wet and asked staff to clean it before Resident #6 was placed into it. Resident #6 stated staff had left them in a wet brief for 5 hours. Staff A stated residents were changed every 2 to 3 hours but reported that around lunchtime Resident #6 had activated the call light to use the bathroom, and Staff A told the resident about lunchtime and planned to return after assisting in the dining room. Staff C stated that if a resident requested bathroom assistance during lunch, staff helped only if sufficient staffing existed, and otherwise told the resident assistance would occur after dining room duties were completed. The DON stated residents should be changed every 2 hours upon rising, before and after meals, at bedtime, and as needed, and that if a resident requests bathroom assistance during a meal, staff must assist before going to the dining room.
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