F0690

D

Failure to Perform and Document Timely Catheter Changes Resulting in UTI and Distress

Pasadena, Texas Survey Completed on 10-13-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent urinary tract infections for residents with indwelling urinary catheters. For Resident #1, record review showed a physician’s order for an indwelling urinary catheter to be changed as needed for blockage and/or leaking, with a related care plan intervention to change the catheter, tubing, and bag per order. The care plan also noted a prior focus that the resident refused catheter changes. However, the August, September, and October 2025 Treatment Administration Records (TARs) contained no documentation of catheter changes, and progress notes did not document refusals or requests for catheter changes during that period.

During observation and interview, Resident #1 reported that staff did not change her catheter every month and stated that staff became upset when she mentioned it. The resident showed the surveyor the urinary drainage bag, which had “8/28/25” written on it and contained brown discoloration; the resident also reported that the bag smelled and that, although she could not feel anything below the waist due to paraplegia, she felt anxious about the catheter not being changed. Later, the resident reported that staff changed her catheter on 10/11/25, and observation at that time showed a clean bag and tubing with no writing on the bag, but this change occurred after the period in which no changes were documented.

For Resident #2, records showed a diagnosis including urinary retention and obstructive/reflux uropathy, with a physician’s order for a suprapubic indwelling urinary catheter to be changed monthly and as needed, starting 9/15/25. The September 2025 TAR documented a catheter change on 9/15/25 by LVN B. Observations on 10/9/25 and again on 10/13/25 showed the same notation on the urinary drainage bag indicating it was installed on “WED 8/27/25 14.00 HRS,” with no evidence of a subsequent bag change. Record review also showed physician orders for Macrobid and Levofloxacin for treatment of a UTI beginning on 10/13/25, and the care plan documented that the resident had frequent UTIs with an intervention for staff to provide catheter care every shift and as needed. Interviews with the Unit Manager and ADON confirmed that catheters were expected to be changed every 30 days and as needed per physician orders and that nurses were responsible for performing and documenting these changes.