Failure to Follow Foley Catheter Orders and Notify Physician of Changes Resulting in Harm to Two Residents
Summary
The deficiency involves the facility’s failure to provide necessary care and services in accordance with physician orders and to notify the physician promptly of significant changes in condition for two residents with Foley catheters. Facility policies required protection from abuse, neglect, and exploitation, prompt notification of changes to physicians and resident representatives, and obtaining a physician or nurse practitioner order prior to Foley catheter irrigation. Despite these policies, staff actions and omissions related to Foley catheter insertion, irrigation, removal, and follow-up care did not comply with physician orders or notification requirements. For the first resident, who had diagnoses including hypertension, GERD, type 2 diabetes mellitus, an orthopedic implant in the left leg, and morbid obesity, the physician had ordered aspirin and Foley catheter care every shift due to wounds. On the day of the incident, an LPN inserted a Foley catheter at the end of the day shift and noted urine return with a small trace of blood. The resident became panicked upon seeing blood in the Foley tubing, and the LPN irrigated the Foley catheter with sterile water without obtaining a physician order, stating that Foley irrigation was basic nursing. Later, during the evening shift, a CNA observed that there was no urine output and blood in the Foley drainage bag and reported this to the assigned LPN. The LPN did not notify the physician about the blood in the Foley drainage bag. Instead of obtaining a physician order, the LPN removed the Foley catheter based on instructions relayed from the former DON, despite having no physician order to discontinue the catheter. After removal, the resident began bleeding from the penis and rectum and developed altered mental status and loss of consciousness. EMS was called and documented that the resident had been bleeding from Foley catheter removal and was experiencing shortness of breath, later becoming unresponsive and going into respiratory arrest. Hospital records indicated that the resident had a Foley catheter placed earlier that day with a large amount of blood expressed and that the onset of shortness of breath coincided with the Foley procedure. The resident was transferred to a second hospital in critical condition, where a urologist placed a Foley catheter with cystoscopy, and bleeding continued from multiple sites. The death certificate listed acute cardiac and respiratory failure, disseminated intravascular coagulation, and urethral injury as the immediate cause of death. For the second resident, who had diagnoses including HIV, morbid obesity, obstructive and reflux uropathy, anemia, chronic pain, hypertensive heart disease, cerebral infarction affecting the left dominant side, uropathy, and an indwelling Foley catheter, the physician ordered a urine sample for urinalysis and culture and removal of the Foley catheter. After admission, the Foley catheter was discontinued, but due to urinary retention concerns it was reinserted, and an order was obtained for UA/C&S and a urology consult because the urine was cloudy with a foul odor. The resident also had orders for a routine monthly catheter change with an 18 Fr 10 cc balloon and to irrigate the catheter with 60 cc normal saline or sterile water as needed for leakage or blockage every eight hours as needed for urinary retention. A laboratory requisition for urinalysis with microscopic sample was dated, but there was no evidence that the urine sample was collected as ordered. Further review of the second resident’s records showed a handwritten lab requisition noting that the resident was discharged to the hospital on a certain date, but there was no documentation in the medical record that the resident was sent to the hospital, and the census did not reflect a leave of absence. There was no indication that the ordered urine specimen was obtained, although a urology appointment was scheduled and later rescheduled. Hospital records documented that the resident was admitted from the nursing home with altered mental status and concern for sepsis, with a chronic indwelling Foley catheter and a history of complicated UTIs. The urinalysis showed extremely turbid urine with high leukocyte esterase and elevated WBCs. The resident was discharged back to the facility with a Foley catheter changed in the emergency department and no antibiotics ordered. Later, facility progress notes documented altered mental status and transfer to the hospital via EMS, where hospital records indicated hypotension and septic shock likely from a UTI or infected decubitus ulcer/osteomyelitis, and that the Foley catheter had reportedly been in place for more than a month. The death certificate listed urosepsis and pneumonia as the immediate cause of death. Staff interviews confirmed the deviations from policy and physician orders. The LPN who inserted the Foley for the first resident acknowledged irrigating the catheter without an order. The CNA on the evening shift reported observing no urine output and significant bleeding from the resident’s penis and rectum and expressed concern that the assigned LPN was not doing enough, prompting her to ask another LPN to call the former DON. The assigned LPN for the first resident confirmed that she removed the Foley catheter without a physician order, following the former DON’s instructions, and that she only texted the physician after deciding to send the resident to the hospital. Another LPN reported that the former DON, overhearing the situation by phone, first instructed that the Foley be flushed and then instructed that it be removed, with the plan to obtain a discontinuation order afterward. For the second resident, an RN stated that she had not changed the Foley catheter on the date the resident was sent to the hospital, and that she noted low oxygen saturation, reported it to the charge nurse, and called the physician, who ordered transfer to the ER.
Penalty
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Below are regulatory guidelines relevant to this citation:
A CNA aggressively slapped and grabbed a resident’s wrist during lunch feeding assistance, then roughly pulled the resident’s hand off his shirt sleeve after she had grabbed it. The CNA had prior disciplinary actions, including a previous feeding incident in which a resident choked and required the Heimlich maneuver. A nurse later assessed the resident and found no bruises or cuts.
A facility failed to protect two residents from resident-to-resident physical abuse. In one incident, a resident with dementia and cognitive impairment was struck during a dispute over TV volume and responded by scratching the other resident. In another, a resident with dementia and physically aggressive behaviors scratched a roommate’s face, leaving superficial marks. Staff interviews and clinical records confirmed both altercations and the resulting injuries.
A resident with a left ankle fracture, muscle weakness, and total-assist transfer needs was supposed to receive 2-person assistance and remain NWB on the left leg. Instead, a nurse aide transferred the resident with only one staff member during a toilet-to-wheelchair transfer, and the resident heard a pop and developed increased pain. X-ray and hospital imaging confirmed fractures of the distal R tibia and fibula, and the facility substantiated neglect for not following the care plan.
Failure to Protect Resident from Repeated Room Intrusions: A cognitively intact resident with depression and hip OA was repeatedly frightened when another resident with dementia and wandering behaviors entered her room, took belongings, and could not be reliably redirected. Staff used a stop sign banner and other barriers, but the other resident continued to enter the room, and the resident became so fearful that she requested discharge before completing her therapy goals.
Failure to protect a resident from alleged physical abuse: A resident with COPD, speech disturbances, and dysphagia reported that an LPN pushed them in the chest during med pass after they refused meds, causing them to fall. The resident had no visible injuries, but the report was documented by nursing staff and the NP, and the resident later reiterated by writing/gestures that the LPN pushed them. The LPN denied pushing the resident and described the contact as accidental, while the facility concluded there was no evidence of abuse.
A resident-to-resident sexual abuse allegation was not thoroughly investigated, and the resident was not promptly protected or monitored after the allegation. In a separate issue, a handwritten sign with personal care instructions was posted above another resident's bed, and an RT, LPN, RN, and CNA all acknowledged it was a privacy and dignity concern and against facility policy.
Failure to Protect Resident from Abuse During Feeding Assistance
Penalty
Summary
The facility failed to ensure a resident’s right to be free from abuse during lunch assistive feeding. While standing about 3 feet from the lunch table, the surveyor heard a CNA aggressively slap Resident #56’s left wrist and observed the CNA grab the resident’s left wrist and roughly pull her hand off of his shirt sleeve after she had grabbed it. The surveyor then continued observing the meal and later reported the incident to the DON and Administrator. Resident #56 was assessed by a licensed nurse after the incident, and no bruises or cuts were found on her wrists. The CNA involved had been hired by the facility in 2024, had signed the facility’s Resident Abuse Procedural Summary, and had attended behavior training in 2026. The CNA also had three prior disciplinary actions, including a prior incident in which a resident choked after being given too large a bite during assistive feeding and required a Heimlich maneuver.
Failure to Protect Residents from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure two sampled residents were free from physical abuse by other residents. One resident with dementia, anxiety, chronic pain, visual hallucinations, and moderate cognitive impairment was involved in an altercation with a roommate after a disagreement about TV volume. The incident escalated when the roommate attempted to take the TV remote and struck the resident with an open hand, and the resident responded by scratching the roommate. The record also documented a new scratch on the resident’s left hand and later noted that the resident no longer wanted to share a room with the other resident. The other incident involved a resident with dementia and significant cognitive impairment who had a behavior care plan for impaired safety awareness and physically aggressive behaviors. The record stated that the resident clawed a roommate in the face, leaving superficial scratches and red marks on the roommate’s chin and cheek. The roommate’s record reflected ongoing monitoring for scratches to the chin and neck, and the roommate stated that the other resident reached up and ran fingernails across her face while they were getting up for breakfast. Facility documentation and staff interviews confirmed both resident-to-resident incidents. Staff described the first event as a physical altercation triggered by conflict over TV volume, and the second as an incident in which one resident scratched another resident’s face. The DON stated the facility investigated and reported the incidents, and also acknowledged that the documentation surrounding the second event was inconsistent and did not meet expectations or policy. The cited deficiency was based on the facility’s failure to ensure the residents were protected from physical abuse by other residents.
Failure to Follow Two-Person Transfer Plan Resulted in Resident Fractures
Penalty
Summary
The facility failed to protect a resident from neglect when staff did not follow the resident’s individualized transfer plan requiring assistance from two staff members. The resident was admitted with a left lower leg trimalleolar fracture, polyosteoarthritis, and muscle weakness, and the MDS indicated the resident was cognitively intact but required total assistance for transfers and toileting. The comprehensive care plan and physician orders both directed staff to provide two-person assistance for transfers and to maintain non-weight-bearing status on the left lower extremity. During a transfer from the toilet to a wheelchair, one nurse aide assisted the resident without a second staff member. According to the documentation, the resident stood without difficulty, but during the pivot transfer the resident’s right foot turned inward and both the resident and the aide heard a loud pop. The resident immediately reported increased pain. Later that day, x-ray findings identified an acute fracture of the right tibia, and the resident was transferred to the hospital emergency department for further evaluation and treatment. Hospital imaging confirmed fractures of the distal right tibia and fibula, and the resident was scheduled for surgical repair. The facility’s investigation determined that the aide transferred the resident with only one staff member despite the care plan and physician order requiring two staff members, and that this failure directly resulted in the resident sustaining the fractures. The facility substantiated caregiver neglect and terminated the employee following the investigation.
Failure to Protect Resident from Repeated Room Intrusions
Penalty
Summary
The facility failed to protect a cognitively intact resident with osteoarthritis of the right hip and major depressive disorder from mental abuse by another resident. The resident was admitted as a vulnerable adult and her care plan identified a goal of being free from abuse, neglect, or financial exploitation, but it did not include interventions to protect her from abuse. The resident later reported that another resident repeatedly entered her room, scared her, and took belongings, and she asked staff to contact her lawyer. She also began using a stop sign banner across her door and later barricaded her room with a walker, closet door, and bedside table because she was afraid of the other resident. The other resident had moderate cognitive impairment, vascular dementia with agitation, and Alzheimer’s disease, and his care plan documented restlessness, agitation, sundowning, wandering into other residents’ rooms, and urinating in public. Progress notes showed repeated episodes of wandering into other residents’ rooms, difficulty with redirection, aggression toward staff, and disruptive behavior in resident rooms. Notes also documented that he entered the affected resident’s room on multiple occasions, and staff observed that he could move barriers out of the way and continue entering the room despite attempts to block access. Staff interviews confirmed that the resident was very scared of the other resident and that the repeated room intrusions continued over several days. Staff stated that stop sign banners did not stop him, closed doors did not stop him, and that it often took two or more staff to remove him from rooms. The resident requested discharge from the facility and left before reaching her maximal level with therapy services. Therapy documentation stated she was improving but still needed higher-level therapy before discharge, and the therapy director stated her early discharge was because she could not remain in the facility due to the other resident coming into her room. Facility records also showed staffing levels that were below the facility assessment on several shifts, and the assignment sheets did not identify a staff member assigned to 1:1 observation for the wandering resident.
Failure to Protect Resident from Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when a nurse allegedly made physical contact with the resident during medication administration. Resident #7, who had diagnoses including COPD, speech disturbances, and dysphagia, had intact cognition on the MDS dated 03/18/2026 and was care planned as at risk for misappropriation, neglect, abuse, and/or exploitation. On 04/08/2026, the resident reported to the RN supervisor that an LPN pushed them in the chest after they refused medications, causing them to fall to the floor. The resident was assessed and no visible injuries were noted. The resident’s report was documented in nursing and medical progress notes, and the facility’s investigation recorded that the resident was visibly upset while describing the incident. The LPN denied the allegation and stated that any contact was accidental, describing that the resident was close behind them as they left the room and that the resident’s chest contacted their back or shoulder. The RN supervisor, DON, and NP each documented interviews and assessments in which no bruising, swelling, or visible injury was found, and the resident later communicated by writing and gestures that they had told the LPN to leave the room and that the LPN pushed them in the chest and they fell. The facility concluded there was no evidence of abuse, neglect, exploitation, or mistreatment, despite the resident’s allegation and the conflicting accounts from the LPN and resident. The RN supervisor stated law enforcement was notified and police interviewed the resident and the LPN, but no report was filed. The DON later stated the contact was accidental and that the resident’s reporting was inconsistent regarding whether a fall occurred.
Failure to Protect Resident from Abuse and Maintain Privacy
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident sexual abuse allegation was not thoroughly investigated and the resident was not promptly protected or monitored after the allegation. The report states this involved 1 of 52 sampled residents, Resident 45, and that the deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse. The facility also failed to protect the privacy and confidentiality of Resident 58. Resident 58 was admitted with diagnoses including chronic obstructive pulmonary disease. During observation, a handwritten sign reading, "Attention please no briefs chucks only!!" was posted above the resident's bed and remained there on a later observation. Staff members including a Respiratory Therapist, LPN, RN, and CNA each acknowledged the sign was visible above the bed and stated it was a privacy, dignity, and policy issue. A facility Residents Rights policy stated residents have the right to privacy and confidentiality with personal care and medical records, and that resident medical and personal care information is private and staff are required to respect and uphold resident privacy at all times.
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