F0689

G

Failure to Supervise High‑Risk Resident Leads to Traumatic Foley Dislodgement

Scottsdale, Arizona Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards for a cognitively impaired, high‑fall‑risk resident with a Foley catheter, resulting in accidental catheter dislodgement and transfer to the hospital. The resident had multiple diagnoses including advanced vascular dementia, non‑Alzheimer’s dementia with behavioral disturbance, anxiety, depression, altered mental status, CHF, cardiomyopathy, pneumonia, and urinary retention. From admission onward, clinical documentation repeatedly described the resident as confused, oriented only to self, very forgetful, encephalopathic, and at high risk for falls, with ongoing behaviors of yelling out, agitation, attempts to self‑ambulate, and repeatedly pulling on his Foley catheter. The care plans and multiple physician and psychiatry notes documented that the resident needed more supervision, had impaired safety awareness, and was at risk for catheter‑related trauma, with goals that the resident remain free from such trauma.

Despite these documented needs, the record showed that the resident continued to yell out instead of using the call light, frequently requested toileting, and pulled on his Foley catheter on numerous occasions, with notes of bloody urine after pulling on the catheter. Providers and psychiatry repeatedly recommended increased supervision and nonpharmacologic strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for agitation, and a consistent sleep routine. Behavior notes also documented multiple attempts by the resident to self‑ambulate to leave the facility, and staff reports that the resident was constantly yelling, shouting, and difficult to redirect. However, there was no evidence that the facility implemented new or enhanced supervision interventions in response to these escalating behaviors, nor evidence that the recommended nonpharmacologic strategies were put in place. Review of the MAR/TAR further showed that a PRN antianxiety medication ordered for anxiety and restlessness was not documented as administered, and no target behaviors were recorded over several days.

On the morning of the incident, observations and video footage showed the resident seated alone in a gerichair across from the nurses’ station with his Foley bag attached to the chair, no call light or call bell within reach, and no television or activity available. Over an extended period, he repeatedly yelled for help, requested water, and requested assistance to use the bathroom. Staff intermittently approached but did not provide toileting assistance, repeatedly left him alone, and at times did not respond at all while he continued to yell loudly. The resident stated he might try to walk and could hurt himself, attempted to stand multiple times, and at one point the unlocked gerichair rolled backward when he partially stood, causing the Foley bag to fall to the floor; staff rehung the bag and again left him seated without continuous supervision. Later, while no staff were in the immediate area, the resident stood and took unsteady steps away from the chair, causing the Foley tubing to pull taut and the catheter with balloon to be dislodged and fall to the floor. The resident yelled in pain and was later found with significant bleeding and clots, leading to his transfer to the emergency department. The surveyors concluded that, despite clear documentation of the resident’s need for increased supervision and his ongoing behaviors of yelling, pulling on the Foley, and attempting to self‑ambulate, the facility failed to implement and maintain adequate supervision and environmental safeguards to prevent this accident.

Additional observations and interviews supported the pattern of inadequate supervision and response to the resident’s behaviors. Video review showed prolonged periods during which the resident yelled for help dozens of times without staff response, and instances where staff walked past him while he requested bathroom assistance without intervening. The gerichair was observed with wheels not securely locked when the resident attempted to stand, contributing to instability. Other residents reported that the man’s yelling had been ongoing and affected their sleep. A CNA reported that the resident had gotten up from his chair before and screamed all the time, and that caring for residents with behaviors was very hard because the facility was understaffed. Throughout the record, there was continued documentation that the resident needed more supervision and might not be appropriate for the facility due to agitation, yet no corresponding increase in supervision or implementation of recommended nonpharmacologic safety measures was documented prior to the catheter‑related injury.