Failure to Administer Ordered Antibiotic Regimen for UTI as Prescribed
Summary
The deficiency involves the facility’s failure to ensure that an ordered antibiotic for a urinary tract infection (UTI) was administered correctly and consistently according to the prescriber’s orders. The resident involved had a history of transient ischemic attack, cerebral infarction without residual deficits, cervical spinal cord lesion, systemic lupus erythematosus, major depressive disorder, and type 2 diabetes with neuropathy, and was frequently incontinent of bowel and bladder. The care plan identified recurrent UTIs and directed staff to administer antibiotic therapy as ordered, monitor for side effects and effectiveness, and obtain and follow up on lab work. A physician order dated 01/23/26 specified nitrofurantoin (Macrobid) 100 mg by mouth every 12 hours for seven days for dysuria due to UTI, with instructions to document adverse effects, check vital signs with each administration, and document whether symptoms were improving. Progress notes show that on 01/23/26 the resident complained of dysuria and frequency, and the NP ordered Macrobid twice daily and a urine specimen for urinalysis and culture and sensitivity, with instructions not to start the antibiotic until after the urine specimen was collected. The MAR indicated the first scheduled dose on 01/24/26 at 6:00 A.M. was not given, and the first actual dose was administered at 6:00 P.M. that day. No doses were given on 01/25/26, and only the morning dose was given on 01/26/26; the resident then received both scheduled doses on 01/27/26 through 01/30/26. In total, the resident received 10 doses instead of the 14 doses ordered. The antibiotic was also started before the urine culture was obtained, contrary to the NP’s direction. There was no documentation that the NP was notified of the delay in sending the urine culture, the early administration of Macrobid before culture collection, or the missed doses and incomplete course of therapy. Additional documentation shows that attempts to obtain a urine specimen on 01/24/26 and 01/25/26 were unsuccessful due to contamination with stool and delayed transportation related to weather, and there was no evidence the NP was notified of these issues. A straight catheter order was later received, and a urine specimen was finally collected on 01/27/26 and reported on 01/29/26, showing >100,000 CFU/mL of E. coli susceptible to nitrofurantoin. A late entry note indicated the urine culture was positive for E. coli and that the resident received Macrobid with symptom improvement. Subsequent NP documentation on 02/11/26 noted the resident had been treated with a course of Macrobid for UTI but continued to report recurrent UTIs with burning and frequency, and a repeat urinalysis on 02/12/26 showed abnormal findings. In interviews, the ADON confirmed the delays in starting Macrobid, the missed doses, the administration of doses before culture collection, and that the NP was not notified, while the NP stated she was not aware the full seven-day course had not been given and that she had not been contacted to address the incomplete antibiotic course. The facility’s medication policy required medications to be administered consistent with physician orders for dose, strength, route, and frequency.
Penalty
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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.
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.
A resident with a Stage 4 sacral pressure ulcer and an indwelling urinary catheter had a physician order for catheter care every shift, but the clinical record showed no documentation of such care over an extended period. A staff member confirmed that catheter care should be performed and documented each shift, and facility guidelines state that trained clinical staff are responsible for indwelling Foley catheter care to prevent CAUTIs. This lack of documented catheter care resulted in a deficiency citation.
Surveyors found that two residents with indwelling and suprapubic catheters did not receive catheter care consistent with facility policy. The policy required drainage bags to be kept below bladder level, emptied when half full, and off the floor. One resident with obstructive uropathy, diabetes, and kidney failure was twice observed in bed with the catheter tubing and urine-filled drainage bag lying on the floor. Another resident with neuromuscular bladder dysfunction and diabetes was observed with a suprapubic catheter drainage bag that was more than half full of urine and resting on the floor. An RN, an LPN, and the DON each acknowledged that the bags should have been emptied as required and kept off the floor.
A resident with moderate cognitive impairment, dependent for toilet hygiene and with multiple medical conditions, was observed receiving incontinent care in which a CNA removed a urine-soaked brief, changed the bed sheet, and applied a clean brief without performing any required perineal cleansing of the front or back. Facility policy and the peri-care skills checklist specified that male residents must have the perineal area, including the penis, scrotum, and inner thighs, washed, rinsed, and dried during incontinent care. The CNA later acknowledged having been trained and competency-checked on this procedure and knowing cleansing was required. Other staff, including a CNA supervisor, an LPN, the DON, and the Administrator, confirmed that proper incontinent care includes full perineal cleansing in addition to brief changes, establishing that the observed omission did not follow facility policy or professional standards intended to prevent UTIs.
Two residents with severe cognitive impairment and documented bladder incontinence care plans were not provided routine incontinence care or scheduled toileting. One resident, always incontinent and dependent on staff for toileting and hygiene, remained seated in the dining area for many hours until staff observed that his pants were saturated with urine, confirming that incontinence care had not been provided. Another resident, also always incontinent and care planned to be toileted every two hours, remained in the dining area for an extended period without toileting; when CNAs eventually provided care, they found a brief and liner completely saturated with strong ammonia-smelling urine, and staff acknowledged the resident had not been toileted for quite some time.
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.
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.
Failure to Provide and Document Ordered Indwelling Catheter Care
Penalty
Summary
The facility failed to ensure ordered catheter care was provided and documented for a resident with an indwelling urinary catheter. The resident, who had diagnoses including a Stage 4 pressure ulcer to the sacrum, was observed on 4/29/26 with an indwelling urinary catheter in place. A physician’s order dated 4/8/26 directed that catheter care be provided every shift. However, review of the clinical record showed no documentation of catheter care being provided between 4/9/26 and 4/29/26. During an interview, a staff member stated that indwelling urinary catheter care should be provided every shift and documented. The facility’s written guidelines for indwelling Foley catheter care, provided by the Regional Director of Operations, stated that the main purpose of proper catheter care is to prevent catheter-associated urinary tract infections and that trained clinical staff will conduct this care. This deficiency was cited under 410 IAC 16.2-3.1-41(2) and related to Intake 2996274.
Failure to Follow Catheter Care Policy for Two Catheterized Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide catheter care in accordance with its own policy for residents with indwelling and suprapubic catheters. The facility’s catheter care policy, last reviewed January 15, 2026, required that catheter drainage bags be positioned lower than the bladder, emptied when half full, and kept off the floor. For one resident with diagnoses including obstructive uropathy, diabetes, and kidney failure, who had an indwelling urinary catheter ordered on January 27, 2026, surveyors twice observed the catheter tubing and urine-filled drainage bag lying directly on the floor while the resident was in bed. During one of these observations, an RN acknowledged that the catheter bag should have been kept off the floor. Another resident, with diagnoses including neuromuscular dysfunction of the bladder and diabetes, had a physician’s order dated December 28, 2024, directing staff to monitor the suprapubic catheter every shift. During observation, this resident was found lying in bed with a catheter drainage bag that was more than half full of urine and resting on the floor. At the time of this observation, an LPN stated that the catheter drainage bag should have been emptied and kept off the floor. In a subsequent interview, the DON confirmed that catheter bags should be emptied and not be in contact with the floor, underscoring that the observed practices did not comply with the facility’s catheter care policy.
Failure to Provide Required Perineal Cleansing During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care in accordance with its own peri-care policy and professional standards of practice for a male resident who was dependent for toilet hygiene. The facility’s written policy for peri/incontinent care for male residents, revised in January 2023, required cleansing of the perineal area starting at the urethra and working outward, including washing and rinsing the penis, scrotum, inner thighs, and perineal area front and back, followed by thorough drying. Record review showed the resident had diagnoses including epilepsy, infection of the skin and subcutaneous tissue, an open wound of the left upper arm, and gastrostomy status, and a Quarterly MDS with a BIMS score of 11 indicating moderate cognitive impairment, with the resident assessed as dependent for toilet hygiene. On the observed date and time, CNA #1 provided incontinent care to this resident by removing a wet urine-soaked brief, changing the fitted sheet, and applying a clean, dry brief without cleansing the resident’s perineal area, front or back, contrary to facility policy. During a subsequent interview, CNA #1 acknowledged she had received in-service training and competency check-offs on peri-care and knew she was supposed to cleanse the perineal area but did not do so, stating she was nervous. Additional interviews with CNA #2 (CNA supervisor and scheduler), an LPN, the DON, and the Administrator confirmed that staff were trained using the Peri Care–Incontinent Care Skills Checklist and that proper incontinent care includes cleansing the perineal area, front and back, in addition to changing the brief. The failure to perform the required cleansing during incontinent care constituted the cited deficiency related to prevention of urinary tract infections.
Failure to Provide Routine Incontinence Care and Scheduled Toileting
Penalty
Summary
The deficiency involves the facility’s failure to provide routine incontinence care and toileting as outlined in residents’ care plans. One resident with severe cognitive impairment, vascular dementia, and multiple comorbidities was care planned for bladder incontinence with interventions such as establishing voiding patterns, monitoring intake and output, encouraging fluids, and monitoring for UTI symptoms. The resident was documented as always incontinent of bladder and frequently incontinent of bowel, and dependent on staff for toileting and personal hygiene. On the survey date, the resident was observed sitting at the dining room table continuously from the start of the survey in the morning until mid-afternoon. By 3:15 P.M., the resident’s pants were visibly wet near the groin, and a CNA confirmed the pants were saturated with urine and that routine incontinence care had not been provided. Another resident, also with severe cognitive impairment, dementia, Alzheimer’s disease, and multiple other diagnoses, had a care plan for actual bladder incontinence related to dementia and need for assistance with personal care. Interventions included toileting every two hours, assistance with toileting and cleansing, use of double briefs to protect dignity, provision of peri-care to maintain cleanliness and dryness, and observation for UTI signs and symptoms. The resident was assessed as always incontinent of bowel and bladder and dependent on staff for toileting and personal hygiene, with no documented refusal of care on the day in question. On that day, the resident was observed sitting at the dining room table from early morning until mid-afternoon without being toileted. When two CNAs finally provided incontinence care, they found the resident wearing a blue brief and a large liner that were completely saturated with strong ammonia-smelling urine. One CNA stated the resident was supposed to be toileted every hour and a half, and the other CNA acknowledged the resident had not been toileted for quite some time.
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