Failure to Monitor and Assess Foley Catheter Care Resulting in Resident Harm
Summary
A deficiency occurred when staff failed to provide appropriate care and monitoring for a resident with quadriplegia and an indwelling Foley catheter. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had a history of acute renal failure, dementia, and dysfunctional bladder. Over a 24-hour period, the resident's urine output was significantly decreased, with only 300 ml recorded, and then zero output documented for the following shift. This decrease in urinary output was not communicated to nursing staff or the physician, and no assessment was performed for possible urinary retention or catheter obstruction. Nursing staff did not conduct assessments or monitor the resident for impaired urinary elimination or changes in urine characteristics, such as color, odor, or clarity, which could indicate a problem with the resident's urinary status. The facility's baseline care plan lacked specific interventions for assessing catheter patency, placement, or complications related to quadriplegia, such as autonomic dysreflexia. Documentation showed that CNAs were responsible for recording urine output, but there was confusion and lack of knowledge among staff regarding what constituted low output and when to notify a nurse or physician. Additionally, a CNA with medication authority signed off on nursing orders, which was outside their scope of practice. The resident was eventually found unresponsive and in respiratory distress, with vital signs indicating a critical condition. Upon transfer to the hospital, the resident was found to have a distended bladder containing 2000 ml of bloody urine with pus, bilateral hydronephrosis, and was diagnosed with severe sepsis, acute respiratory failure, and myocardial infarction. Staff interviews revealed a lack of training and knowledge regarding the care of residents with indwelling catheters and those with special needs such as quadriplegia. The failure to monitor, assess, and communicate changes in the resident's urinary status directly led to the resident's hospitalization and critical illness.
Removal Plan
- Education for all nurses and CNAs on daily catheter care, as well as monitoring and reporting of urinary output, was completed by the DON or designee.
- Nurses were educated on how to perform bladder assessments for residents with indwelling catheters, with a special focus on residents unable to communicate or who are paralyzed.
- All residents with indwelling catheters were audited for their last catheter change date and ensured accurate physician's orders were obtained for the next catheter change.
- The electronic medication administration record (eMAR) was reviewed to ensure accurate orders were in place, including those for catheter care, urinary output monitoring, and catheter replacement.
- All residents with indwelling catheters were assessed by the DON for bladder fullness to ensure proper catheter drainage.
- An as needed catheter change physician's order was added for another identified resident affected by the deficient practice.
- A shift evaluation for residents with dwelling catheters was implemented, including assessments of bladder status, urine output, potential blockages, and urine characteristics, to be conducted by floor nurses and documented in the eMAR.
- Abnormal findings from the floor nurse will be reported to the director of nursing and the on-call physician.
- All new admissions, readmissions, and newly ordered indwelling Foley catheters will be audited by the DON or designee to ensure catheter insertions are completed in accordance with physician's orders.
- All new admissions with indwelling catheters will be audited by the DON or designee to confirm the presence of appropriate physician orders and nursing interventions for daily catheter care.
- The audit will be completed by the director of nursing or designee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition and multiple diagnoses, including BPH and stroke, had a physician order for a condom catheter at bedtime, but the EMR lacked orders or instructions for cleaning, disinfecting, monitoring, or changing the drainage bag. During observation, the bag was seen hanging in the bathroom, and an LPN, RN case manager, and DON all confirmed the absence of documented guidance for the catheter drainage bag care.
A resident with a suprapubic catheter had incomplete orders and unclear care coordination. The care plan did not identify the SP catheter or who was responsible for catheter care and bag changes, and the MAR/TAR contained repeated orders to clarify catheter size without a documented size in the orders. Staff interviews showed uncertainty about the catheter size, who would change the catheter, and whether the listed contact number was available at all times.
Surveyors found that two residents with indwelling urinary catheters did not receive care consistent with their care plans, physician orders, or facility policy. Catheter collection bags were repeatedly observed resting directly on the floor when residents were in bed or seated, and the bags were not contained in basins as specified for one resident. Required catheter care every shift was not documented, and an LPN reported that a catheter bag hung on a recliner had slipped down. The facility’s written policy required keeping catheter bags below bladder level and off the floor, as well as providing routine hygiene, but these standards were not followed.
The facility failed to provide and document catheter care for multiple residents with Foley or suprapubic catheters. A resident with a suprapubic catheter developed drainage, vomiting, and sepsis secondary to CAUTI, while other residents had repeated catheter pain, pus, blockage, hematuria, UTIs, and hospital transfers, including ICU admission for septic shock. The record showed no catheter care orders or task documentation for several residents, and the NHA and DON confirmed the missing documentation.
A resident receiving short-term rehab with an indwelling urinary catheter was observed in a wheelchair with the catheter drainage bag hung under the seat and touching the floor, despite facility documentation requirements that staff verify each shift that privacy bags are in place and drainage bags are not on the floor. An RN confirmed that catheter bags are not supposed to touch the floor, indicating a failure to follow established catheter care and infection control practices.
Indwelling Catheter Drainage System Left on Floor: A resident with CKD and a UTI had an indwelling urinary catheter, but staff observed the catheter tubing and drainage bag on the floor on multiple occasions. An LPN also lifted the bag above the level of the bladder while repositioning it, and staff interviews confirmed the bag and tubing should not touch the floor.
Missing Orders and Documentation for Condom Catheter Drainage Bag Care
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for management of a resident’s external urinary catheter system. The resident had intact cognition and required assistance with ADLs, and diagnoses included atrial fibrillation, heart failure, BPH, stroke, malnutrition, anxiety disorder, and depression. Physician orders dated 4/29/26 indicated use of a condom catheter at bedtime, but the electronic medical record did not contain physician orders or documented instructions for cleaning, disinfecting, monitoring, or routinely changing the associated catheter drainage bag. During observation on 5/19/26 at 11:57 a.m., the resident’s catheter drainage bag was seen hanging on the side rail in the bathroom. Record review and observation did not identify documentation that the drainage bag was routinely cleaned, disinfected, monitored, or replaced according to accepted standards of practice. An LPN confirmed there were no physician orders addressing when the drainage bag should be changed or instructions for cleaning or disinfecting it. An RN case manager stated the drainage bag should have been changed weekly, but no orders related to changing, cleaning, or disinfecting were present. The DON stated the facility expected clear physician orders and nursing instructions for catheter care, cleaning, monitoring, and replacement schedules, and confirmed the facility could not provide evidence that such orders or guidance were in place for the resident’s condom catheter drainage bag care.
Incomplete Suprapubic Catheter Orders and Care Coordination
Penalty
Summary
The facility failed to ensure proper orders were obtained and adequate coordination was in place for a resident with a suprapubic catheter. The resident’s admission MDS identified intact cognition and an indwelling catheter. During interview, the resident stated he had a catheter before admission and that it was changed to a suprapubic catheter after moving to the facility because of infections. The resident also stated staff assisted with the catheter. The resident’s care plan addressed bladder incontinence and included brief use, perineal care, incontinence checks, and monitoring for signs and symptoms of UTI, but it did not identify that the resident had a suprapubic catheter or who was responsible for catheter care and changing the drainage bag. The MAR/TAR contained multiple catheter-related orders, including orders to clarify catheter size, change the drainage bag and tubing, clean around the suprapubic catheter exit site, monitor for leakage and infection, and flush the catheter if not draining properly. Several of these orders were left blank on some shifts or days, and the record showed repeated orders to clarify the catheter size without a documented size in the orders. Progress notes showed catheter-related documentation, including a resident refusal of catheter care, a successful suprapubic catheter exchange at the urologist office, and later documentation that the catheter was patent and sized at 16 fr. Staff interviews showed uncertainty about the current catheter size, whether the facility was responsible for catheter changes, and whether the contact number listed for catheter problems was available 24 hours a day. The DON stated orders should include the catheter size and clear responsibility for catheter changes in case of emergency, and the facility policy titled Indwelling Catheter Use and Removal did not address suprapubic catheters.
Failure to Maintain Proper Indwelling Catheter Care and Bag Positioning
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate indwelling urinary catheter care and to keep catheter collection bags off the floor for two residents with catheters. For one resident with paraplegia, cognitive communication deficit, and an indwelling catheter, surveyors repeatedly observed the catheter collection bag resting directly on the floor, both when the resident was in bed and when she was seated in a recliner. The bag was not contained in a basin despite a care plan revision indicating the catheter bag was to be kept in a basin on the floor per the resident’s preference, with the basin next to the bed. There were no physician orders or documentation indicating that catheter care was being provided, even though the resident’s care plan included interventions such as catheter care per orders and positioning the catheter bag and tubing below the level of the bladder. An LPN later stated she had hung the catheter bag on the side of the recliner and that it must have slipped down. For a second resident with diagnoses including obstructive and reflux uropathy and hydronephrosis with ureteral stricture, surveyors observed on multiple occasions that the urinary catheter collection bag was attached to the side of the bed in a low position and resting directly on the floor, without being contained in a basin. The resident’s care plan and physician orders required catheter care every shift and positioning the catheter bag and tubing below the level of the bladder. The facility’s own policy on indwelling urinary catheter management specified that the collecting bag must be kept below the level of the bladder and not rested on the floor, and that routine hygiene was appropriate. Despite these requirements, the observed practices for both residents did not comply with the care plans, physician orders, or facility policy.
Failure to Provide and Document Catheter Care
Penalty
Summary
The facility failed to provide adequate urinary catheter care for four residents with indwelling or suprapubic catheters. The report states that the facility policy required catheter care to be documented in the medical record, including the date and time care was provided, the staff member providing it, and assessment data obtained during care. For Resident 6, who had a suprapubic catheter, the record contained no order for catheter care and no task documentation showing catheter care had been completed since admission. Resident 6 developed suprapubic catheter drainage with serosanguinous fluid, vomiting, and later presented to the hospital with low suprapubic output, blood-tinged leakage, pus around the suprapubic tube, pus and gross hematuria in the tubing, suprapubic abdominal pain, and vomiting. The resident was admitted with sepsis secondary to CAUTI. The Nursing Home Administrator and DON confirmed there was no order or documented evidence that catheter care had been provided per policy. Resident 28’s record also lacked an order for catheter care and lacked task documentation showing catheter care had been completed since admission. The resident had repeated catheter-related complaints and findings, including pain, reports that nurses were not flushing the catheter, pus around the catheter, sediment nearly occluding the Foley, yellow drainage, redness, swelling, hematuria, and multiple transfers to the hospital. The record documents UTIs, positive urinalysis results, antibiotic treatment, and hospital admissions including sepsis. The NHA confirmed there was no documented evidence of catheter care for this resident. Resident 47 had a Foley catheter order, but the record failed to show an order for catheter care or documentation that catheter care had been completed since admission. The resident complained of abdominal and penile discomfort, a Foley flush met resistance, the catheter was changed, the resident remained unable to void, and a bladder scan showed 1211 cc with a hard, distended abdomen. The resident was sent to the hospital and was admitted to ICU with septic shock from ESBL Klebsiella and E. coli bacteremia from complicated UTI/CAUTI present on admission. Resident 8’s record likewise lacked an order for catheter care and lacked task documentation showing catheter care from return from the hospital until discontinuation of the catheter. The NHA and DON confirmed the absence of documented catheter care for Resident 8 as well.
Catheter Drainage Bag Allowed to Touch Floor, Breaching Infection Control
Penalty
Summary
The facility failed to provide appropriate services to prevent urinary tract infections for one resident with an indwelling urinary catheter. A male resident admitted for short-term rehabilitation after a fall with a right femur fracture, and with diagnoses including malignant neoplasm of the prostate and secondary malignant neoplasm of the bone, was observed sitting in a wheelchair in the hallway with his indwelling urinary catheter drainage bag hung under the wheelchair seat and touching the floor. Facility records on the Treatment Administration Record showed staff were required to document each shift that the privacy bag was in place and that the urine collection bag was not touching the floor. During an interview, an RN confirmed that urine collection bags for all residents with indwelling urinary catheters are not supposed to touch the floor. This deficient practice exposed residents with urinary catheters to contaminants that may cause preventable urinary tract infections and had the potential to affect all residents with a urinary catheter.
Indwelling Catheter Drainage System Left on Floor
Penalty
Summary
The facility failed to ensure proper management of a resident’s indwelling urinary catheter drainage system by keeping it off the floor. Resident 25 had a diagnosis that included chronic kidney disease and had a care plan dated 3/26/26 identifying the use of an indwelling urinary catheter. The care plan interventions included maintaining a closed system with the urinary bag below the resident’s bladder and covering and observing the tubing while avoiding obstructions. The resident also had a nurse’s note dated 4/22/26 indicating a urine culture was received and reported to the physician, and a new order was received for Augmentin for a urinary tract infection. During observations, the resident’s catheter tubing was seen lying flat directly on the floor with the tubing coiled around the catheter, the drainage bag was hanging on the bedrail with the bottom slightly off the floor and was then placed onto the bed, and the bag later was observed scrunched up on the floor. During one observation, an LPN lifted the catheter bag above the level of the resident’s bladder while moving it onto the bed. Interviews with CNA 8 and the IP/LPN indicated the catheter bag and tubing should not be on the floor, and the IP/LPN stated that if the bag was on the floor it could cause infections or possible leaks.
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