F0552

G

Resident forcibly catheterized for urine specimen after refusing procedure

Arlington, Virginia Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to uphold a resident’s right to refuse care and treatment when attempting to obtain a urine specimen from Resident #42. The resident had diagnoses including benign prostatic hyperplasia and was documented on the admission MDS with a BIMS score of 4/15, indicating severely impaired cognition for making daily decisions, and was coded as always incontinent. A physician’s order directed that a urinalysis with culture and sensitivity be obtained every shift for three days. On the evening in question, the LPN attempted to collect a urine sample via in-and-out catheterization after the resident was unable to void into a urinal.

According to the facility’s synopsis and staff statements, when the LPN entered the room to insert the catheter, the resident verbally and physically resisted the procedure. A friend visiting the resident reported that the resident said “Don’t do that” and crossed his legs, and later grabbed his penis to stop the nurse. The LPN then called for assistance from two CNAs. The friend was asked to step into the hallway, where she heard the resident yelling but could not make out his words. CNA #14 reported that he and CNA #15 held the resident’s legs and arms while the LPN catheterized him, and the facility’s investigation concluded that the CNAs restrained the resident’s arms and legs during the catheter insertion. The LPN confirmed that the resident was restrained during the procedure and stated that restraining residents during care was common practice, and she expressed surprise when informed that residents have the right to refuse care and cannot be restrained against their will.

During the catheterization, bright blood was noted in the urine sample, and the LPN stopped the procedure and removed the catheter. A health status note documented that the resident appeared anxious but stable, with no signs of shock or distress at that time, and the on-call NP was notified and directed staff to monitor the resident. Later that night and early the following morning, staff documented that the resident had discomfort and pain with urination, hematuria, and blood clots noted in the brief, and the NP ordered transfer to the emergency room. The resident was hospitalized due to hematuria and returned with an indwelling urinary catheter and blood in the urine. The facility’s grievance report and internal investigation documented that the urine catheter was placed for a specimen after the resident’s refusal, that staff held the resident down during the procedure, and that the incident was substantiated as abuse and a violation of the resident’s rights.

Interviews with other staff further described the expected procedure for obtaining a urine specimen and the requirement to stop if a resident refuses, asks to stop, or shows distress, and to notify the physician if urine cannot be obtained. The Senior Director of Nursing Services, another LPN, and a CNA all acknowledged that residents have the right to refuse care, treatments, or procedures and agreed that the resident’s rights were violated in this incident. The facility’s abuse, neglect, and exploitation policy states that each resident has the right to be free from abuse and that team members must not engage in or permit abuse. The events described show that, despite the resident’s severe cognitive impairment, staff proceeded with catheterization by physically restraining the resident after he verbally and physically resisted, resulting in bleeding, pain with urination, hematuria, and hospitalization.