F0690

D

Failure to Manage Catheter-Associated UTI and Notify Physician for Change in Urinary Status

Lima, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

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.