Failure to Manage Catheter-Associated UTI and Notify Physician for Change in Urinary Status
Summary
The deficiency involves the facility’s failure to provide necessary care and treatment for a resident with an indwelling urinary catheter who exhibited signs and symptoms of a urinary tract infection (UTI). The resident had multiple medical diagnoses including diabetes mellitus, Down’s syndrome, Hirschsprung’s disease, and obstructive and reflux uropathy, and was severely cognitively impaired and dependent on staff for ADLs. The resident had an order for a 16 French catheter to straight drain with catheter care every shift and as needed. On 04/09/25, nursing documentation noted purulent drainage from the catheter site, a small amount of grey-green drainage from the catheter, and the resident’s complaint of pain with urination. A UA with reflex culture was ordered on 04/11/25, and the UA showed yellow, turbid urine with positive hemoglobin, nitrates, WBCs, and RBCs, and a urine culture was ordered. On 04/14/25, the physician progress note documented the resident was seen for a UA concerning for UTI and that an antibiotic was being started, with no other complaints. The catheter was changed on 04/16/25 per the monthly schedule. The 04/16/25 urine culture showed greater than 100,000 pseudomonas, and the paper copy of the culture had a handwritten order for Bactrim DS twice daily for seven days with an illegible signature. However, the April 2025 MAR contained no documentation that Bactrim or any other antibiotic was administered, and subsequent physician notes on 04/22/25 and 04/30/25 did not address urinary status. The NP monthly note dated 05/19/25 also did not address urinary status. The MDS nurse later confirmed that Bactrim was not administered as ordered and that no repeat UAs were obtained in April or May 2025. On 05/23/25 at 5:30 A.M., a nurse’s note documented that the resident yelled out that he could not urinate, the catheter had no output, the abdomen was distended and hard, and a CNA reported no urine output for the entire shift. The nurse removed the old Foley catheter, observed a large amount of green foul-smelling discharge from the penis, inserted a new catheter using sterile technique, and obtained 500 cc of dark, odorous urine, with a culture collected. There was no documentation that the physician was notified of these UTI symptoms or decreased urinary output, and the only new order on 05/23/25 was for a genital culture, which later showed normal flora, with no orders for UA or other labs related to UTI symptoms. The record also lacked documentation of physician notification or the reason for the resident’s transfer to the hospital on 05/28/25, where the resident was diagnosed with UTI, atypical pneumonia, and GERD and prescribed Levofloxacin. Facility policies on urinary catheter care and change of condition required observation and reporting of changes in urine output and resident condition to a nurse and physician, but the documented care and communication did not reflect adherence to these policies.
Plan Of Correction
F690 Bowel/Bladder Incontinence, Catheter, UTI The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #51 is no longer in the facility. How you will identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken? Residents residing in the facility with indwelling catheters may be affected by the same practice. There are currently 7 residents with catheters in the building. All seven have been assessed on 4-2-26 for symptoms of UTI by the infection preventionist and none have current symptoms of UTI 4-2-26. At the time of assessments, there were no concerns What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee educated the nursing staff on or before 4-9-2026 about the necessary care and treatment of catheter care to prevent catheter-associated urinary tract infections (UTI). This education includes symptoms of UTI. Nurses and STNAs were educated to identify and report a change in a resident's baseline mental, behavioral, or physical status to a nurse and a medical doctor. The nurse would assess the resident's condition based on the information reported. Staff were inserviced on symptoms of UTI. Emergency care for the residents would be provided if appropriate and /or necessary, the physician would be notified if warranted, emergency services would be contacted for transport if warranted, and the party responsible would be notified of a change in mediation or treatment or if the resident was transferred for acute care . Monitor closely for medications ordered. The facility will ensure that the deficient practice does not recur. How the corrective action will be monitored to ensure the deficient practice will not recur. Audits of residents all 7 residents with catheters are being audited weekly by DON/ or designee. If there are more catheters in place they will be added to the number of residents with catheters being audited. The DON/designee will audit for care and signs of infection by observation of the resident, interview with the resident and reviewing progress notes. audit started 4-1-2026 and are ongoing 5xaweek for 4 weeks. Results are supplied to the QAPI team weekly. If concerns are identified, the MD will be notified and staff reeducated in the process of assessing for uti and care and treatment to prevent UTIs.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with an indwelling catheter and severe cognitive impairment had catheter drainage care observed to be inconsistent with the care plan and facility policy. An RN placed the urine graduate on the floor while emptying the leg bag and did not cleanse the drainage outlet with an alcohol swab, and the resident’s drainage bag was later observed lying directly on the floor instead of being kept in a privacy bag or hung on the bed frame.
Failure to Monitor Catheter-Associated UTI Signs: A resident with dementia, muscle weakness, and protein-calorie malnutrition had a physician order to monitor and report signs of catheter-associated UTI, but staff did not complete the ordered monitoring. The resident was observed with white, milky urine in the catheter tubing and bag on multiple days, the MAR showed the monitoring order was not completed, and the CNO stated the cloudy urine was the resident’s baseline and that no physician notification was documented.
Failure to provide and document condom catheter care for a resident with stroke, contractures, cognitive communication deficit, kidney disease, and chronic sacral ulcers. The resident had a condom catheter placed to help with bladder incontinence and sacral ulcer healing, but the physician orders did not identify the catheter or required care, the care plan only addressed patency, urine output, and skin checks, and the chart lacked catheter care, catheter changes, and skin assessments for an extended period. An incident report showed the catheter became dislodged and caused a 7 cm penile laceration.
Inadequate catheter and perineal care was observed for multiple residents with urinary devices and incontinence needs. A resident with an indwelling catheter had cloudy urine, sediment, bleeding, pain, and an unsecured catheter after staff reportedly pulled on it during care. Other residents were found with urine- and stool-soiled clothing, bedding, and catheter dressings, leaking or dangling urinary tubes, delayed brief changes, and incomplete peri-care that did not include the full frontal perineum, labial folds, urethra, or catheter area.
A resident with a suprapubic indwelling catheter, bladder dysfunction, and a recent UTI was observed in the dining room with the catheter drainage bag hooked to the wheelchair and resting in direct contact with the floor on more than one occasion. Staff, including a CNA, an LPN, and the DON, acknowledged the bag should not have been on the floor, and the facility policy and CDC guidance cited in the report state the drainage bag should be kept below the bladder and not rested on the floor.
Improper Nephrostomy Drainage Positioning: A resident with MS, neurogenic bladder, and a left nephrostomy tube had the drainage bag hung from a wheelchair armrest with tubing positioned above the insertion site, preventing dependent urine drainage. A TMA said this was the usual setup, and the RNCM and DON confirmed the bag and tubing were incorrectly positioned and not allowing urine to drain appropriately.
Improper catheter drainage bag handling and emptying
Penalty
Summary
The facility failed to ensure urinary drainage bags were maintained in a manner that reduced the risk of contamination during catheter care for a resident with an indwelling catheter. The resident had severe cognitive impairment and diagnoses including ichthyosis vulgaris, major depressive disorder, mixed obsessional thoughts and acts, bipolar disorder, candidiasis of skin and nails, and anxiety. The care plan directed staff to ensure the catheter bag was hung on the bed frame and not placed directly on the floor, to use a privacy bag at all times, and to switch between a leg bag during the day and a night bag at night. During observation, an RN emptied the resident’s catheter leg bag by placing the urine graduate directly on the floor before draining the bag into it, and the drainage outlet was closed without being cleansed with an alcohol swab. On another observation, the resident’s catheter drainage bag was lying directly on the floor beside the bed while the resident was in bed with the leg bag secured to the left leg. A NA later changed the resident’s catheter bed bag to a leg bag. The DON stated staff were expected to place the catheter bag into a privacy bag to prevent it from lying on the floor, and the facility policy directed staff to cleanse the outlet with an alcohol swab after draining urine.
Failure to Monitor Catheter-Associated UTI Signs
Penalty
Summary
The facility failed to ensure proper monitoring was conducted to identify potential catheter-associated urinary tract infections for Resident #32, who was admitted and later readmitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. A physician order dated 2/14/25 directed staff to monitor, record, and report signs and symptoms of catheter-associated urinary tract infection, including pain, burning, blood-tinged urine, cloudiness, no output, deepening urine color, increased pulse, increased temperature, urinary frequency, foul-smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. Resident #32 was observed with white, milky urine in the catheter tubing flowing into the catheter bag on 7/7/26, 7/8/26, and 7/9/26. The MAR for 7/1/26 through 7/10/26 documented "No" for completion of the physician order to monitor, record, and report signs and symptoms of catheter-associated urinary tract infection. On 7/10/26 at 10:29 AM, the CNO stated she would not document a change when the urine appeared milky white because this was the resident's baseline, said the monitoring order was not appropriate because cloudiness would be normal for him, and confirmed the record did not include documentation of physician notification regarding urine changes.
Failure to Provide and Document Condom Catheter Care
Penalty
Summary
Appropriate care was not provided for the use of a condom urinary catheter for one resident. The resident was admitted with diagnoses including stroke, contractures, cognitive communication deficit, kidney disease, and chronic sacral ulcers, and a condom catheter was placed on 2/6/26 to help assist in healing a sacral ulcer due to bladder incontinence. The resident's MDS dated 5/5/26 showed the diagnoses remained current. The facility's catheter care policy stated that nursing provides bathing and hygiene, male genitalia are to be cleansed with the foreskin retracted and the meatus wiped, rinsed, patted dry, and the foreskin replaced, and that staff are to document all care and services provided. The resident's current physician orders did not identify the condom catheter or the care required, and the care plan only directed staff to check patency, urinary output, and skin for breakdown. An incident report dated 6/2/26 showed the resident developed a 7 cm laceration of the penis when the condom catheter became dislodged. Clinical documentation did not include catheter care, catheter changes, or skin assessments from 3/28/26 through 5/31/26, when the catheter became dislodged. During interview, the Nursing Administrator confirmed that documentation did not include catheter care, catheter changes, or skin assessments during that period.
Inadequate catheter and perineal care
Penalty
Summary
The facility failed to ensure indwelling urinary catheters and perineal care were provided in a manner intended to prevent urinary tract infection for 4 of 4 residents reviewed for catheter and perineum care. The report describes multiple observations of residents with urinary catheters that were unsecured, soiled, or not cleaned as part of incontinence care, along with delayed or incomplete perineal hygiene after bowel or bladder incontinence episodes. R11, who had diagnoses including rectal cancer, retroperitoneal abscess, colostomy status, diabetes, neuromuscular bladder dysfunction, muscle wasting, and obesity, was observed with cloudy urine, sediment in the catheter tubing, and later cloudy urine mixed with bright red blood after staff reportedly pulled on the catheter during care. The catheter was noted to be unsecured, and the resident reported sharp urethral pain and ongoing discomfort. The catheter remained unsecured over the following days. R10, who had quadriplegia, multiple sclerosis, neuromuscular bladder dysfunction, hydronephrosis, cystostomy status, and a history of UTI, was found with urine-saturated clothing, dressings, and bedding, leaking suprapubic and nephrostomy tubes that were dangling loosely, and fecal matter adhered to the buttocks and skin. R21, who had diabetes, chronic kidney disease, urinary retention, and morbid obesity, waited for incontinence care after a bowel movement, and when care was provided, only the back perineum was cleaned while the frontal perineum and urinary catheter were not cleaned. R15, who had diabetes and morbid obesity, was heavily saturated with urine and bowel movement, and staff cleaned only part of the perineal area, leaving the labial folds, urethra, and inner groin folds uncleaned.
Catheter Bag Resting on Floor
Penalty
Summary
The facility did not ensure appropriate catheter care for a resident with a suprapubic indwelling catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder, presence of urogenital implants, and retention of urine, and the physician ordered the suprapubic catheter to be changed every 4 weeks with urology evaluation every 6th catheter change. The resident’s care plan identified actual, at-risk, and potential complications related to suprapubic catheter use and included use of a dignity bag for the Foley when not in the room. The resident also had been treated for a UTI in 5/2026. Surveyors observed the resident eating lunch in the dining room with the catheter bag hooked on the bottom of the wheelchair and resting in direct contact with the floor. The same condition was observed again while the resident was eating breakfast in the dining room on a later date. Staff were notified each time, and a CNA, an LPN, and the DON acknowledged that the catheter bag should not have been touching the floor. The facility policy stated catheter drainage bags should be covered at all times while in use, and the CDC guidance cited in the report states the collecting bag should be kept below the bladder and not rested on the floor.
Improper Nephrostomy Drainage Positioning
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a left nephrostomy drainage system when the tubing and bag were positioned in a way that did not allow unobstructed dependent drainage of urine. R5’s quarterly MDS identified moderately impaired cognition, need for assistance with ADLs, and diagnoses including multiple sclerosis, neurogenic bladder, and septicemia. The care plan identified altered elimination related to MS, decreased mobility, a left nephrostomy tube related to kidney stones, and Foley catheter placement, and directed staff to monitor for UTI signs and symptoms, provide perineal care, and empty the left nephrostomy as ordered. During observation, R5 was seated in a Broda wheelchair with the nephrostomy drainage bag hanging from the left armrest and the tubing positioned off the side of the wheelchair and above the insertion site. This placement prevented dependent drainage of urine and created the potential for urine backflow. A TMA stated the bag was typically hung that way. The RNCM and DON later observed the system and confirmed the bag and tubing were positioned incorrectly, stating the bag needed to remain below the insertion site to allow urine to flow freely and reduce the risk of UTIs. The facility’s Indwelling Catheter Care Procedure directed staff to provide appropriate care of urinary drainage systems and to place drainage tubing over the resident’s leg and check the tubing for evidence of urine flow.
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