Failure to Monitor Urinary Retention After Foley Removal Leading to Prolonged Pain
Summary
The deficiency involves the facility’s failure to adequately assess and monitor a resident for complications associated with an indwelling urinary catheter and urinary retention, particularly after catheter removal. The resident had a history of acute kidney injury due to urinary retention, which improved after Foley catheter placement in the hospital. Hospital discharge documentation indicated the catheter was placed for acute urinary retention, was deemed permanent, and included instructions that, given the resident’s significant retention and acute renal failure, staff at the skilled nursing facility should not attempt Foley removal. The facility’s catheter care plan directed staff to empty the catheter as needed and record output in milliliters, but review of the last 30 days of documentation showed continence was not rated due to the indwelling catheter and there was no documented urinary output in milliliters on the treatment administration records. The resident had a scheduled urology appointment at which the urinary catheter was discontinued. Upon return from this appointment, nursing documentation initially indicated no new orders, and an alert note later stated the catheter was discontinued and staff were monitoring for retention or pain. However, there was no documented bladder assessment or urinary output following catheter removal. Nursing assistant documentation showed that the resident did not void on the evening shift that same day. Despite the catheter having been removed, the treatment administration record showed staff continued to document provision of catheter care on subsequent shifts when no catheter was in place. Over the next day, the resident experienced vomiting, decreased oral intake, and an altered level of consciousness, with vital signs showing tachycardia and low blood pressure, and staff documented decreased urine output. A bladder scan performed later revealed more than 2000–2500 milliliters of urine in the bladder, and an indwelling catheter was reinserted, initially draining a large volume of urine. The provider note indicated the resident had not eaten since the prior night, was unable to hold down fluids, and staff were unsure whether the resident had urinated in incontinence briefs, with no wet briefs reported since the resident’s return from the hospital after catheter removal. The provider expressed concern that the documented early-morning wet brief might not be accurate given the large bladder volume on scan and stated this should require further investigation. Subsequent notes described the resident moaning and complaining of pain, with limited urine output in the catheter bag and staff flushing and then replacing the catheter due to continued complaints. Interviews with the resident, the roommate, and staff indicated the resident was crying out and moaning in pain, the roommate repeatedly alerted staff that the resident was not urinating and that the catheter was not draining, and staff had to seek assistance to replace the catheter. Facility leadership and clinical staff later acknowledged that typical practice after catheter removal would include contacting the provider, placing the resident on alert, performing post-void residuals with bladder scans, and documenting monitoring, which was not done in this case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with an indwelling catheter and severe cognitive impairment had catheter drainage care observed to be inconsistent with the care plan and facility policy. An RN placed the urine graduate on the floor while emptying the leg bag and did not cleanse the drainage outlet with an alcohol swab, and the resident’s drainage bag was later observed lying directly on the floor instead of being kept in a privacy bag or hung on the bed frame.
Failure to Monitor Catheter-Associated UTI Signs: A resident with dementia, muscle weakness, and protein-calorie malnutrition had a physician order to monitor and report signs of catheter-associated UTI, but staff did not complete the ordered monitoring. The resident was observed with white, milky urine in the catheter tubing and bag on multiple days, the MAR showed the monitoring order was not completed, and the CNO stated the cloudy urine was the resident’s baseline and that no physician notification was documented.
Failure to provide and document condom catheter care for a resident with stroke, contractures, cognitive communication deficit, kidney disease, and chronic sacral ulcers. The resident had a condom catheter placed to help with bladder incontinence and sacral ulcer healing, but the physician orders did not identify the catheter or required care, the care plan only addressed patency, urine output, and skin checks, and the chart lacked catheter care, catheter changes, and skin assessments for an extended period. An incident report showed the catheter became dislodged and caused a 7 cm penile laceration.
Inadequate catheter and perineal care was observed for multiple residents with urinary devices and incontinence needs. A resident with an indwelling catheter had cloudy urine, sediment, bleeding, pain, and an unsecured catheter after staff reportedly pulled on it during care. Other residents were found with urine- and stool-soiled clothing, bedding, and catheter dressings, leaking or dangling urinary tubes, delayed brief changes, and incomplete peri-care that did not include the full frontal perineum, labial folds, urethra, or catheter area.
A resident with a suprapubic indwelling catheter, bladder dysfunction, and a recent UTI was observed in the dining room with the catheter drainage bag hooked to the wheelchair and resting in direct contact with the floor on more than one occasion. Staff, including a CNA, an LPN, and the DON, acknowledged the bag should not have been on the floor, and the facility policy and CDC guidance cited in the report state the drainage bag should be kept below the bladder and not rested on the floor.
Improper Nephrostomy Drainage Positioning: A resident with MS, neurogenic bladder, and a left nephrostomy tube had the drainage bag hung from a wheelchair armrest with tubing positioned above the insertion site, preventing dependent urine drainage. A TMA said this was the usual setup, and the RNCM and DON confirmed the bag and tubing were incorrectly positioned and not allowing urine to drain appropriately.
Improper catheter drainage bag handling and emptying
Penalty
Summary
The facility failed to ensure urinary drainage bags were maintained in a manner that reduced the risk of contamination during catheter care for a resident with an indwelling catheter. The resident had severe cognitive impairment and diagnoses including ichthyosis vulgaris, major depressive disorder, mixed obsessional thoughts and acts, bipolar disorder, candidiasis of skin and nails, and anxiety. The care plan directed staff to ensure the catheter bag was hung on the bed frame and not placed directly on the floor, to use a privacy bag at all times, and to switch between a leg bag during the day and a night bag at night. During observation, an RN emptied the resident’s catheter leg bag by placing the urine graduate directly on the floor before draining the bag into it, and the drainage outlet was closed without being cleansed with an alcohol swab. On another observation, the resident’s catheter drainage bag was lying directly on the floor beside the bed while the resident was in bed with the leg bag secured to the left leg. A NA later changed the resident’s catheter bed bag to a leg bag. The DON stated staff were expected to place the catheter bag into a privacy bag to prevent it from lying on the floor, and the facility policy directed staff to cleanse the outlet with an alcohol swab after draining urine.
Failure to Monitor Catheter-Associated UTI Signs
Penalty
Summary
The facility failed to ensure proper monitoring was conducted to identify potential catheter-associated urinary tract infections for Resident #32, who was admitted and later readmitted with diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. A physician order dated 2/14/25 directed staff to monitor, record, and report signs and symptoms of catheter-associated urinary tract infection, including pain, burning, blood-tinged urine, cloudiness, no output, deepening urine color, increased pulse, increased temperature, urinary frequency, foul-smelling urine, fever, chills, altered mental status, changes in behavior, or changes in eating patterns. Resident #32 was observed with white, milky urine in the catheter tubing flowing into the catheter bag on 7/7/26, 7/8/26, and 7/9/26. The MAR for 7/1/26 through 7/10/26 documented "No" for completion of the physician order to monitor, record, and report signs and symptoms of catheter-associated urinary tract infection. On 7/10/26 at 10:29 AM, the CNO stated she would not document a change when the urine appeared milky white because this was the resident's baseline, said the monitoring order was not appropriate because cloudiness would be normal for him, and confirmed the record did not include documentation of physician notification regarding urine changes.
Failure to Provide and Document Condom Catheter Care
Penalty
Summary
Appropriate care was not provided for the use of a condom urinary catheter for one resident. The resident was admitted with diagnoses including stroke, contractures, cognitive communication deficit, kidney disease, and chronic sacral ulcers, and a condom catheter was placed on 2/6/26 to help assist in healing a sacral ulcer due to bladder incontinence. The resident's MDS dated 5/5/26 showed the diagnoses remained current. The facility's catheter care policy stated that nursing provides bathing and hygiene, male genitalia are to be cleansed with the foreskin retracted and the meatus wiped, rinsed, patted dry, and the foreskin replaced, and that staff are to document all care and services provided. The resident's current physician orders did not identify the condom catheter or the care required, and the care plan only directed staff to check patency, urinary output, and skin for breakdown. An incident report dated 6/2/26 showed the resident developed a 7 cm laceration of the penis when the condom catheter became dislodged. Clinical documentation did not include catheter care, catheter changes, or skin assessments from 3/28/26 through 5/31/26, when the catheter became dislodged. During interview, the Nursing Administrator confirmed that documentation did not include catheter care, catheter changes, or skin assessments during that period.
Inadequate catheter and perineal care
Penalty
Summary
The facility failed to ensure indwelling urinary catheters and perineal care were provided in a manner intended to prevent urinary tract infection for 4 of 4 residents reviewed for catheter and perineum care. The report describes multiple observations of residents with urinary catheters that were unsecured, soiled, or not cleaned as part of incontinence care, along with delayed or incomplete perineal hygiene after bowel or bladder incontinence episodes. R11, who had diagnoses including rectal cancer, retroperitoneal abscess, colostomy status, diabetes, neuromuscular bladder dysfunction, muscle wasting, and obesity, was observed with cloudy urine, sediment in the catheter tubing, and later cloudy urine mixed with bright red blood after staff reportedly pulled on the catheter during care. The catheter was noted to be unsecured, and the resident reported sharp urethral pain and ongoing discomfort. The catheter remained unsecured over the following days. R10, who had quadriplegia, multiple sclerosis, neuromuscular bladder dysfunction, hydronephrosis, cystostomy status, and a history of UTI, was found with urine-saturated clothing, dressings, and bedding, leaking suprapubic and nephrostomy tubes that were dangling loosely, and fecal matter adhered to the buttocks and skin. R21, who had diabetes, chronic kidney disease, urinary retention, and morbid obesity, waited for incontinence care after a bowel movement, and when care was provided, only the back perineum was cleaned while the frontal perineum and urinary catheter were not cleaned. R15, who had diabetes and morbid obesity, was heavily saturated with urine and bowel movement, and staff cleaned only part of the perineal area, leaving the labial folds, urethra, and inner groin folds uncleaned.
Catheter Bag Resting on Floor
Penalty
Summary
The facility did not ensure appropriate catheter care for a resident with a suprapubic indwelling catheter. The resident had diagnoses including neuromuscular dysfunction of the bladder, presence of urogenital implants, and retention of urine, and the physician ordered the suprapubic catheter to be changed every 4 weeks with urology evaluation every 6th catheter change. The resident’s care plan identified actual, at-risk, and potential complications related to suprapubic catheter use and included use of a dignity bag for the Foley when not in the room. The resident also had been treated for a UTI in 5/2026. Surveyors observed the resident eating lunch in the dining room with the catheter bag hooked on the bottom of the wheelchair and resting in direct contact with the floor. The same condition was observed again while the resident was eating breakfast in the dining room on a later date. Staff were notified each time, and a CNA, an LPN, and the DON acknowledged that the catheter bag should not have been touching the floor. The facility policy stated catheter drainage bags should be covered at all times while in use, and the CDC guidance cited in the report states the collecting bag should be kept below the bladder and not rested on the floor.
Improper Nephrostomy Drainage Positioning
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a left nephrostomy drainage system when the tubing and bag were positioned in a way that did not allow unobstructed dependent drainage of urine. R5’s quarterly MDS identified moderately impaired cognition, need for assistance with ADLs, and diagnoses including multiple sclerosis, neurogenic bladder, and septicemia. The care plan identified altered elimination related to MS, decreased mobility, a left nephrostomy tube related to kidney stones, and Foley catheter placement, and directed staff to monitor for UTI signs and symptoms, provide perineal care, and empty the left nephrostomy as ordered. During observation, R5 was seated in a Broda wheelchair with the nephrostomy drainage bag hanging from the left armrest and the tubing positioned off the side of the wheelchair and above the insertion site. This placement prevented dependent drainage of urine and created the potential for urine backflow. A TMA stated the bag was typically hung that way. The RNCM and DON later observed the system and confirmed the bag and tubing were positioned incorrectly, stating the bag needed to remain below the insertion site to allow urine to flow freely and reduce the risk of UTIs. The facility’s Indwelling Catheter Care Procedure directed staff to provide appropriate care of urinary drainage systems and to place drainage tubing over the resident’s leg and check the tubing for evidence of urine flow.
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