Failure to Maintain Proper Urinary Catheter Care and Assessment
Penalty
Summary
The deficiency involves the facility’s failure to provide urinary catheter care and services in accordance with professional standards for two residents. For one resident with chronic kidney disease (Stage 4) and obstructive uropathy, surveyors repeatedly observed the urinary catheter drainage bag detached from the bed and resting directly on the floor, with urine that appeared slightly cloudy. These observations occurred multiple times on the same day, despite the treatment administration record indicating catheter care was provided and a care plan directing staff to keep the drainage bag below bladder level and off the floor. During interviews, a CNA and an LPN both stated that catheter bags should be kept off the floor to prevent infection and that they routinely check catheter tubing, drainage bag placement, and urine characteristics, yet the resident’s catheter bag remained on the floor during the LPN’s visit to the room. The DON also confirmed that CNAs are responsible for catheter care and that catheter bags should not be on the floor. For another resident with obstructive uropathy, renal disease, communicating hydrocephalus, altered mental status, dementia, and acidosis, the care plan identified use of a urinary catheter with risk for infection and complications and directed staff to change the drainage bag routinely and as needed and to provide daily catheter care. Daily skilled nursing notes documented clear, yellow urine and normal abdominal findings on several days. However, the resident was later found lethargic and not responding to verbal stimuli, and was sent to the hospital, where records showed admission for severe sepsis secondary to UTI, life-threatening hypernatremia, and acute kidney injury. A CT scan revealed the catheter balloon was inflated in the urethra rather than the bladder, causing a significantly distended bladder and bilateral hydroureteronephrosis. Despite this change in condition, there was no documented assessment of urinary catheter patency, and interviewed staff, including an LPN and CNAs, had no recollection of the resident’s catheter status, though they described general practices of frequent rounding, monitoring, and emptying catheter bags.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.