F0690

G

Failure to Monitor and Manage Indwelling Catheter Leading to Worsening Penile Injury and Urine Leakage

Houston, Texas Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate care and monitoring for a male resident with an indwelling urinary catheter, resulting in worsening penile injury and leakage of urine into his incontinent brief. The resident had significant medical conditions including hypertension, stage 3 pressure ulcers, neurogenic bladder, obstructive and reflux uropathy, and used an indwelling catheter. His MDS showed severe cognitive impairment, total dependence for toileting, and incontinence of bowel and bladder. His care plan and physician orders required staff to follow catheter-related orders, monitor the catheter site every shift for signs of infection, irritation, urethral erosion, and leakage, and to monitor urine characteristics and report abnormalities to the physician.

Surveyor review of prior documentation showed that during an earlier survey, the resident’s penis had a small slit measuring 0.3 cm by 0.1 cm with slight redness, and there was no leg strap or Statlock securing the catheter. CNAs at that time reported they had not previously seen the slit. Despite ongoing orders to monitor for complications each shift, the March MAR entries indicated nurses signed off that there were no issues with the Foley and skin area. However, during a later observation of catheter and incontinent care, the resident’s penis was found to be slit from the meatus down the shaft, with a beefy red color and fresh bleeding. The slit had increased in size to 1.5 cm by 0.5 cm. When the area was wiped, the wipes showed a substantial amount of blood. Staff interviews indicated that the slit had been present and known to some staff for weeks, but they described it as smaller and not bleeding previously.

During the same observation, the resident’s brief was saturated with urine, the wetness indicator was not visible, and the wound dressing near the buttock was wet and non-adhesive, with a second dressing soaked. The Foley tubing contained smears of sediment with no urine visible in the tubing, and the Foley bag held cloudy urine with a significant amount of sediment. The nurse assigned to the resident stated he had made rounds twice that day but had not noticed Foley leakage or assessed the penis, and he acknowledged he was aware of the slit from prior orientation but believed it was regular wear and tear from Foley use. He also stated he was not aware of the leakage until he saw the soaked brief and sediment in the tubing and bag, and he did not identify when to obtain an order to flush the catheter. The NP later reported she had not been informed that the slit had worsened, had not been notified of leakage or balloon issues, and had not given the ointment order the nurse described. Other staff, including CNAs, the ADON, DON, and Corporate Nurse, confirmed the slit had been smaller previously, that the Foley had been leaking onto the brief, and that sediment and potential clogging could cause leakage and skin breakdown, but these changes and complications were not consistently recognized, monitored, or reported as required by the resident’s orders and care plan.