F0690

K

Failure to Assess and Manage Abnormal Catheter Urine Leading to Septic Shock

Burleson, Texas Survey Completed on 03-11-2026

Penalty

Fine: $204,535

Summary

The deficiency involves the facility’s failure to ensure that a resident with an indwelling urinary catheter received appropriate assessment, intervention, and catheter management in response to persistent abnormal urine characteristics and signs of possible infection. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an indwelling catheter, colostomy, and feeding tube, and was dependent on staff for all ADLs. Her care plan identified her as having a catheter, being at risk for UTIs, and having frequent UTIs, with specific interventions to monitor urine for color, sediment, odor, amount, and to report abnormalities such as blood-tinged urine, cloudiness, no output, deepening of urine color, and other signs of UTI to the physician. Physician orders directed that the Foley catheter and drainage bag be changed PRN for signs of infection, obstruction, or compromise of the closed system.

On one date, an LVN documented that the resident’s catheter was draining blood-tinged urine, that her blood pressure was low, and that the physician was notified, resulting in orders for a UA and IV fluids. The resident later refused IV fluids, and a UA collected showed blood, protein, mucus, and WBC clumps, with blood and protein flagged as critical, but there were no documented follow-up orders or interventions after these results. The NP documented dark orange/red urine and noted a contaminated UA with mixed microbial growth, ordering a repeat UA and labs, and recorded that the resident had refused IV fluids. The NP stated that dark orange urine could be normal if related to minor bleeding from catheter movement but that dark brown/black urine would not be normal and should be reported; she also stated that whenever a UA was ordered, staff were supposed to change the catheter. The electronic record showed the resident’s indwelling catheter was last changed several months earlier, with no documentation of catheter changes, urine color/characteristics, or change in condition from that date through the days immediately preceding the resident’s transfer to the hospital.

Multiple staff interviews and video evidence showed that the resident’s urine had been dark brown to black and foul-smelling for weeks without appropriate assessment, documentation, or escalation. CNAs and LVNs reported that the urine appeared reddish, like iced tea, brown/blackish, and had a bad odor for approximately a month or a few weeks, and that they assumed it was normal after it remained that way; several nurses acknowledged they did not assess the catheter or urine every shift and did not consistently document or notify the physician about the worsening color. Video footage provided by the responsible party showed dark/black, opaque urine in the drainage bag on multiple nights, and hospital staff described the catheter on admission as draining purulent, very dark/black urine with foul odor, pus in the tubing, and mold on the catheter balloon and tip, suggesting it had not been changed for a long time. The facility’s own catheter policy required timely and appropriate assessments, ongoing monitoring for catheter-associated UTI, recognition and reporting of complications, and catheter and drainage bag changes based on clinical indications such as infection or obstruction. Despite these requirements and the resident’s known history of frequent UTIs and chronic catheter use, the facility did not assess, intervene, or change the catheter while the resident’s urine remained abnormal over an extended period, culminating in her transfer to the hospital where she was diagnosed with severe sepsis with septic shock likely from a UTI.