F0690

D

Failure to Assess and Manage Indwelling Urinary Catheters and Voiding Trials

Olympia, Washington Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to monitor and justify the continued use and removal of indwelling urinary catheters for two residents, and to follow ordered protocols for voiding trials and post-void residual (PVR) monitoring. For one resident with a history of left hip fracture, diabetes mellitus, benign prostatic hyperplasia, and urinary obstruction, the admission MDS and care plan documented the presence of an indwelling catheter and general catheter care tasks, but there was no assessment addressing possible removal of the catheter. Hospital transition orders recommended temporary catheter management per nursing protocol for urinary retention, yet the facility did not document evaluation of the ongoing need for the catheter. During a multidisciplinary care conference with the family, staff reviewed the resident’s care needs but did not address the indwelling catheter or infection risk related to its continued use.

Subsequent nursing notes for this resident documented that blood was noted in the catheter because the resident was trying to pull it out, and an outside orthopedic provider later expressed concern that the catheter had remained in place since hospitalization, recommending removal when medically acceptable due to high infection risk and noting the resident had not received the care specifically needed. The facility’s alleged neglect investigation, initiated after the family reported concerns that staff refused to remove the catheter, concluded there was no abuse or neglect but did not address the continued use of the catheter. Staff interviews revealed that LPNs waited for direction from the nurse manager for catheter removal, that the supervising LPN was unsure whether the provider had been contacted about removal for this resident, and that if a provider chose to keep a catheter in place this decision would not be documented. The supervising LPN agreed there was no justification for continued catheter use and acknowledged that a voiding trial was only started on the day of discharge at another facility, and the DON confirmed there was no documentation of assessment for appropriateness of continued catheter use.

For a second resident admitted with a lower leg fracture and urinary retention, the care plan documented an indwelling catheter but left the reason for the catheter blank, and the admission assessment noted no factors related to urinary incontinence and no justification for continued catheter use. Provider notes indicated the resident had a UTI and urinary retention in the hospital, had failed a voiding trial, and was started on medication for urinary retention. Later provider notes ordered removal of the catheter and initiation of bedside commode use, with specific orders to scan the bladder every shift for 72 hours, perform straight catheterization if bladder volume exceeded a set threshold, and replace the indwelling catheter after a third failed attempt. The record showed the catheter was removed and that the resident subsequently failed a voiding trial and required reinsertion of an indwelling catheter, but there was no documentation of PVRs during the initial ordered monitoring period. When the catheter was later removed again, there was no corresponding provider order in the record and no PVR monitoring to ensure the resident could tolerate removal. Staff interviews confirmed that PVRs were not done when ordered, that no urology consultation was obtained despite ongoing urinary retention, and that PVR monitoring before discharge was inconsistent. Discharge documentation noted the resident would need catheter replacement upon discharge and later documented difficulty voiding and high PVR with straight catheterization, without mention of post-catheterization care, further PVRs, or urology follow-up.