F0658

D

Unauthorized Straight Catheterization and Use of Physical Restraint to Obtain Urine Specimen

Arlington, Virginia Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to follow professional standards of practice when obtaining a urine specimen for Resident #42, who had severe cognitive impairment and was always incontinent per the most recent MDS. The physician’s order for the resident specified a UA with culture and sensitivity every shift for three days but did not include an order to obtain the specimen via straight catheterization. Despite this, on the evening of 01/28/2025, an LPN attempted an in-and-out catheterization to collect the urine sample after determining the resident was unable to urinate into a urinal. During the procedure, bright blood was noted in the urine sample, and the catheter was removed. The LPN notified the on-call NP and documented that the resident appeared anxious but stable.

According to the facility’s internal investigation and staff statements, the LPN called two CNAs into the room when the resident became combative during the catheterization attempt. The resident’s friend, who was present initially, reported that the resident said “Don’t do that” and crossed his legs when the nurse attempted to insert the catheter, and that staff then asked her to step into the hallway. While in the hallway, she heard the resident yelling. CNA statements and the facility’s synopsis of the event documented that the CNAs held the resident’s arms and legs while the LPN inserted the catheter in order to obtain the urine specimen. The facility’s investigation concluded that the resident was restrained during the procedure and that this was a common practice according to the LPN’s own statement, despite the resident’s right to refuse care.

Following the catheterization, the resident was later noted around 5:00 a.m. on 01/29/2025 to have discomfort and pain with urination, hematuria, and blood clots in the brief. Vital signs were documented as stable, and the on-call NP was notified and ordered transfer to the ER. The resident returned from the hospital later that day with an indwelling urinary catheter and blood in the urine. The facility’s grievance report documented that the resident and representative alleged a catheter was used for a urine sample against the resident’s will, resulting in injury and hospitalization. The facility’s Medical Director and nursing leadership, when interviewed by surveyors, stated that professional standards required a physician’s order for straight catheterization if a clean-catch specimen could not be obtained and that the procedure should be stopped and the physician notified if the resident refused or showed distress. They acknowledged that the LPN and CNAs did not follow these standards when they proceeded with catheterization without a specific catheter order and while the resident was being held down.