Failure to Assess and Manage Abnormal Catheter Urine Leading to Septic Shock
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.
Removal Plan
- Performed a 100% audit (DON, ADON, Wound Care Nurse) of residents with catheters to verify catheter placement/securement, urine characteristics, signs/symptoms of UTI, EMR documentation accuracy, and catheter change dates.
- Replaced any urinary catheter immediately (by a licensed nurse) for residents with abnormal findings; notified physician immediately, implemented new orders promptly, and increased monitoring every shift.
- Provided a 1:1 in-service to the LVN who failed to document catheter change on the importance of documenting all care provided (including catheter changes), with progressive discipline up to termination for further infractions.
- Completed an in-service for all licensed nurses and CNAs on catheter care/maintenance, UTI prevention, change-in-condition notification, documentation requirements, and when to notify the physician; staff were not permitted to return to resident care until in-services were completed.
- Implemented DON/designee review of resident changes in condition via SBAR, documentation, and initiated interventions during clinical meetings; addressed issues immediately with the licensed nurse and/or IDT, resident/RP, and physician as necessary; adopted as standard IDT review process for residents with catheters.
- Implemented DON/designee verification of catheter orders and documentation of catheter care and assessments; adopted as standard IDT review process for residents with catheters.
- Conducted visual checks by DON/designee to ensure catheter care is maintained and without abnormalities until 100% compliance is achieved; communicated potential issues to the IDT, resident/RP, and physician.
- Implemented a questionnaire process to validate effectiveness of the urinary catheter care process with licensed nurses, CNAs, and nurse managers; provided immediate re-education if staff could not answer appropriately.
- Ran a physician orders report to check and verify accuracy of any new catheter orders; immediately corrected issues; adopted as standard IDT review process for residents with catheters.
- Clarified and corrected incomplete/incorrect/conflicting catheter orders/documentation immediately when identified by DON/designee; adopted as standard IDT review process for residents with catheters.
- Conducted an impromptu QAPI meeting with the Medical Director to obtain approval of the action plan.
- Reported findings to the QI process and QA committee monthly (Administrator and DON/designee) and addressed any concerns/recommendations immediately.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with an indwelling urinary catheter, ordered for urinary retention related to hydronephrosis, was observed in bed with the catheter collection bag lying flat on the floor beside the bed and containing urine. The resident said an aide had helped her back to bed after breakfast, and one aide confirmed she assisted the resident but forgot to hang the bag from the bed frame as she normally would. The DON and Administrator stated catheter bags were expected to be kept off the floor.
Catheter care and securement were not maintained for three residents with indwelling catheters. One resident's drainage bag was found lying in bed with tubing under the leg and no strap in place, another resident's tubing was under the leg with no strap present, and a third resident received catheter care from a CNA who cleansed the catheter using a back-and-forth motion and reused the same wipe instead of cleaning away from the penis in one direction. The DON and other staff stated the bag should be below the bladder, the strap should secure the tubing, and catheter care should be performed using proper technique.
A resident with a catheter for neurogenic bladder, impaired cognition, and total bowel/bladder incontinence had a catheter drainage bag repeatedly observed hooked on a wheelchair arm rest above bladder level. The tubing contained urine that had not drained down, the resident tried to move the tubing to drain it, and staff interviews confirmed the bag should have been positioned below the bladder; one RN also stated the resident was on antibiotics for a bladder infection.
Foley Bag Placed at Bladder Level During Care: A resident with an indwelling Foley catheter, severe cognitive impairment, and obstructive uropathy had his drainage bag emptied and then placed on the bed at bladder level during perineal care. Observation showed urine moving back toward the catheter insertion site while the resident was repositioned. Staff interviews confirmed the bag should remain below the bladder at all times, and the facility policy required the drainage bag to be positioned lower than the bladder to prevent backflow.
A resident with a Foley catheter was observed with the tubing not secured to the leg during care, and staff acknowledged it should have been secured to prevent pulling and injury. In a separate observation, two CNAs provided incontinent care to another resident with bowel incontinence and an indwelling catheter but did not clean the inner thighs or right buttock area before applying a clean brief, despite the care plan and facility policy requiring thorough perineal cleansing.
A resident with a catheter was observed with the catheter bag and tubing exposed outside the privacy bag and resting directly on the floor, and the resident moved the wheelchair over the bag. An RN later confirmed that catheter bag and tubing should not be in direct contact with the floor.
Catheter Bag Left on Floor Beside Bed
Penalty
Summary
Failure to provide appropriate catheter care occurred for a resident with an indwelling urinary catheter. The resident was admitted with diagnoses including overactive bladder, hydronephrosis, and bladder-neck obstruction, and the physician ordered a urethral catheter for urinary retention related to hydronephrosis, with instructions to ensure the tubing was patent and the catheter was in a privacy bag. The resident’s assessment identified the resident as cognitively intact and coded the resident as having an indwelling catheter, and the care plan included interventions to position the catheter bag and tubing below the level of the bladder. During an observation, the resident was in bed with visitors present, and the urinary catheter collection bag was lying flat on the floor beside the bed with urine in the bag. The resident stated a nurse aide had assisted her back to bed after breakfast and that she had not touched the catheter bag. One nurse aide stated she had not assisted the resident, while another nurse aide confirmed she assisted the resident back to bed and stated she normally hangs catheter bags from the bed frame when residents are returned to bed, but acknowledged she must have forgotten to do so in this instance. The DON and Administrator both stated the facility expected catheter bags to be kept off the floor and hung from the bed frame when a resident was in bed.
Catheter Care and Securement Not Maintained
Penalty
Summary
The facility failed to ensure appropriate catheter care and catheter securement for three residents with indwelling catheters. Resident #20 had diagnoses including respiratory failure, anoxic brain damage, overactive bladder, and urinary retention, and was dependent for ADLs with severe cognitive impairment. Her care plan directed staff to keep the drainage bag below the bladder at all times, and the order summary required the catheter strap to be in place and holding every shift. During observation, her catheter drainage bag was lying in the bed at the foot of the bed, the tubing was under her right leg and curled on the bed, and no catheter strap was present. RN B stated the drainage bag was not in the right place. Resident #46 had diagnoses including respiratory failure, quadriplegia, epileptic seizure, and dysphagia, and was also severely cognitively impaired and dependent for ADLs. His care plan included catheter care under enhanced barrier precautions, and the order summary required the catheter strap to be in place and holding every shift. During observation, his catheter tubing was under his right leg and no catheter strap was in place. LVN A stated the resident had a shower that day and may have come off in the shower, and he verified that there was an order for the catheter strap to be in place. Resident #7 had a history of cerebral infarction, hemiplegia and hemiparesis, and urinary tract infection, with severe impairment in cognitive skills for daily decision making. His care plan directed staff to ensure tubing was anchored to the resident's leg or linens so it was not pulling on the urethra. During observation, CNA E provided catheter and incontinence care while the resident was without a leg strap for the catheter tubing. CNA E cleansed the catheter by rubbing it back and forth at the point where it met the penis and then used the same wipe again in a manner that did not follow the expected one-direction cleansing technique. The DON later stated staff were expected to clean away from the penis in one fluid motion and not go back with the same soiled wipe.
Catheter Drainage Bag Positioned Above Bladder Level
Penalty
Summary
The facility failed to ensure a catheter drainage bag remained below the level of the bladder for a resident with a catheter for neurogenic bladder. The resident’s quarterly MDS identified moderately impaired cognition, rejection of care one to 3 days, dependence on staff for dressing, bed mobility, and toileting, and that the resident was always incontinent of bowel and bladder with intermittent catheterization. The care plan directed staff to position the catheter bag and tubing below the level of the bladder, and the facility’s urinary catheter care policy stated the drainage bag should be held or positioned lower than the bladder to prevent backflow. During observation, the resident’s catheter drainage bag was repeatedly found hooked on the wheelchair arm rest above the level of the bladder while the resident was in the commons area and later in the dining room. The catheter tubing contained urine that had not drained down, and the resident stated he was moving the tubing to try to get urine to drain into the bag. Staff interviews confirmed the bag should have been below the bladder for drainage, and one RN stated the resident was on antibiotics for a bladder infection. Multiple staff observed the incorrect placement, and nursing staff did not intervene while the resident was at an activity for about 1 and 1/2 hours.
Foley Bag Placed at Bladder Level During Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with an indwelling Foley catheter. Resident #38 was admitted with diagnoses including obstructive and reflux uropathy, dementia, and age-related physical debility. The resident’s MDS reflected severe cognitive impairment with a BIMS score of 07, and the care plan identified the need for an indwelling Foley catheter due to obstructive uropathy related to penile and scrotal swelling, along with a potential for UTI. The care plan also directed staff to keep the urine collection bag below the level of the bladder and off the floor at all times. During observation of perineal care, the resident’s urine collection bag was removed from the bed frame after being emptied and placed inside a clear plastic bag on the resident’s bed next to his left leg. At that time, the Foley bag was at the level of the resident’s bladder. The observation further showed yellow urine moving from the middle of the catheter toward the insertion site at the resident’s penis while the resident was repositioned from his back to his right side. The Foley bag remained on the bed until the incontinent care was completed. Interviews confirmed that staff understood the bag should remain below the bladder to prevent backflow of urine, and the CNA acknowledged it was his mistake that the bag was placed on the bed. The DON stated she instructed the CNA to empty the bag, cover it with a plastic bag, and place it on the bed during care. The facility’s catheter care policy stated that the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.
Unsecured Foley Catheter and Incomplete Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with an indwelling Foley catheter. Resident #7 was admitted with obstructive and reflux uropathy, had an order for a Foley catheter with a leg strap to be monitored each shift and as needed, and had a care plan addressing catheter-related trauma and urinary infection prevention. During observed catheter care, the Foley catheter tubing was not secured to the resident’s leg. CNA D and CNA E both stated they did not notice the catheter was unsecured, and both acknowledged that the catheter should be secured to prevent twisting, pulling, and injury. The DON also stated that indwelling catheters should be secure to prevent pulling and possible injury. The facility also failed to provide complete incontinent care for a resident who was incontinent of bowel and had an indwelling catheter. Resident #34 had severe cognitive impairment, was dependent on staff for toileting and personal hygiene, and had a care plan directing staff to cleanse the perineal area with mild cleanser after each episode. During observed incontinent care, CNA J and CNA G cleaned the penis, scrotum, and catheter tubing, and cleaned the left buttock and perineum after the resident had a small bowel movement. However, after the soiled brief was removed and a clean brief was placed, neither CNA cleaned the resident’s inner thigh areas or the right buttock area. During interview, CNA J stated she was not aware that the inner thighs and right buttock had not been cleaned and said those areas should have been wiped. CNA G stated she had received training on incontinent care and acknowledged that if the inner thigh and buttock areas were not properly cleaned, the resident could get an infection. The facility’s perineal/incontinent care policy stated that for a male resident staff should wipe the perineal area including the penis, scrotum, inner thighs, and rectal area thoroughly, including under the scrotum, the anus, and the buttocks.
Catheter Bag and Tubing Left in Contact With Floor
Penalty
Summary
Appropriate catheter care was not provided for Resident R144, who was observed seated in a wheelchair in the entrance of the resident's assigned room with the catheter bag outside of the privacy bag. Approximately the bottom third of the catheter bag and the tubing were resting directly on the floor, and the resident moved the wheelchair and ran over the exposed catheter bag. When the situation was brought to RN15's attention, RN15 secured the catheter bag and tubing off the floor. RN15 confirmed that appropriate treatment and care of the catheter bag and tubing was to ensure it was not in direct contact with the floor.
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