Failure to Follow Catheter Orders and Monitor Output Resulting in Catheter-Related Harm
Summary
The deficiency involves the facility’s failure to follow physician and urology orders regarding an indwelling urinary catheter, failure to develop and implement a comprehensive and individualized care plan for catheter management, and failure to consistently monitor and document urinary output for a cognitively impaired resident. The resident was admitted without a catheter and was initially continent of bladder, requiring staff assistance with toileting. After an episode of urinary retention and UTI, the resident was hospitalized, treated with antibiotics, and discharged back to the facility with a urinary catheter in place, with orders for catheter care twice daily that were carried out from mid‑July through mid‑August. On a subsequent outpatient urology visit, the urologist determined the resident was no longer in urinary retention, documented only 30 ml in the bladder, and removed the catheter, indicating a suprapubic catheter would be preferable if retention recurred. No new physician orders reflecting catheter removal were entered into the facility record on that date, and the existing catheter care orders remained active. That evening, catheter care was not documented, but starting the next day, multiple nurses documented providing catheter care despite the catheter having been removed at the urology office. Within days, the resident again had a urinary catheter in place, but there were no physician orders in the record to reinsert it, no documentation of a comprehensive assessment supporting reinsertion, and no evidence of communication with the physician or urologist to obtain such orders. The CNP later documented that the catheter had been removed at urology and “somehow” had been reinserted, and indicated that orders were given to remove the catheter, but no corresponding physician orders were entered on those dates. A physician order was eventually written to remove the catheter and discontinue associated orders, but this order was not carried out, and catheter care orders remained active for several more days. During the period after the urology visit, staff documented catheter care but failed to consistently monitor and record urinary output from the catheter, with only two output values recorded over nearly two weeks, despite facility policy requiring accurate daily output records and monitoring for abnormal volume or appearance. Vital signs remained stable until a later date when the resident’s blood pressure dropped. A bladder scan order was entered and a scan documented, but the record lacked documentation explaining the clinical rationale for the scan. Later that morning, staff found the resident non‑responsive, pale, and with beige, creamy drainage and pus and blood noted at the penile meatus and in the catheter bag. The resident was sent to the hospital, where imaging showed a severely distended bladder with hydronephrosis and a malpositioned Foley catheter balloon inflated in the membranous urethra, requiring removal and repositioning. Hospital records attributed sepsis, acute kidney injury, and bladder outlet obstruction with hydronephrosis to the catheter‑related obstruction, and the resident required ICU care before eventually stabilizing and being discharged to another facility with hospice. Interviews with multiple RNs and LPNs who had provided care indicated they believed the resident had a catheter in place the entire time and denied knowledge of any orders to remove it or any complications or monitoring concerns related to catheter output. They also denied reinserting the catheter or obtaining orders for reinsertion. A CNA recalled that on one day shortly after the urology visit, the nurse may have noticed the catheter was not present and assumed the resident had pulled it out, and vaguely recalled that the nurse on duty might have reinserted it, though the identified nurse denied doing so. The CNP confirmed that review of call logs showed no calls from the facility to the physician office to obtain reinsertion orders after the urology visit, and that she had raised concerns about this issue with the facility. The Regional Nurse Consultant confirmed there was no documentation of a comprehensive assessment supporting catheter reinsertion, no evidence explaining the need for the later bladder scan, inconsistent monitoring of urinary output, and that the physician order to remove the catheter was not completed as ordered. Facility policies required proper handling of telephone orders and accurate monitoring and documentation of urine volume and appearance, but these were not followed for this resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
