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 multiple health conditions, including multiple sclerosis and vascular dementia, did not receive timely incontinence care, resulting in wet clothing and a saturated brief. The CNA responsible had not attended to the resident for several hours due to other duties, and the facility's policy lacked specific guidelines for care frequency. The DON confirmed that care should be provided every two hours.
The facility failed to assess and treat urinary incontinence for a resident with multiple health issues, lacking a comprehensive bladder assessment and care plan. Another resident had an indwelling urinary catheter without documented justification, with no known reason for its use confirmed by staff and representatives.
A facility failed to provide proper incontinence care for a resident with Alzheimer's and dementia. The care plan required cleansing the perineum after each episode, but a CNA did not follow the correct procedure, particularly in cleaning the uncircumcised penis. The CNA admitted to being trained differently at the facility, which led to the deficiency.
The facility failed to provide proper indwelling catheter care for two residents, with one lacking adequate indication for catheter use and another missing documentation of catheter output. An LPN noted a diagnosis without supporting documentation, and the facility lacked a policy on catheter use reasons. The Administrator confirmed missing output records, violating the facility's urinary catheter care policy.
A resident with severe cognitive impairment and dependency on staff for personal hygiene received inadequate incontinence care. The CNA used two wet washcloths without a barrier, soap, or wash basin, and did not follow proper hand washing and glove use procedures. The facility's policy for incontinence care, which includes using a mild cleanser and applying a protective barrier ointment, was not adhered to during the care provided.
A facility failed to provide necessary incontinence care for a cognitively impaired resident with a history of cerebral infarction and dementia. The resident, who was always incontinent, was found with a soiled brief and saturated bedding, indicating a lack of timely care. Interviews revealed the resident was particular about who provided her care, and effective interventions were not in place to manage her preferences. The facility did not provide evidence of care being refused or performed by night shift staff.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, which was identified during a review of medical records, observations, staff interviews, and policy reviews. The resident, who was admitted with diagnoses including multiple sclerosis, vascular dementia, and hemiplegia, was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting and personal hygiene. The plan of care indicated that staff should change the resident per protocol, preference, and as needed. On a specific observation, the resident was found with wet pants and a saturated incontinence brief with a strong urine odor, indicating a lack of timely care. The CNA responsible for the resident's care admitted to not providing incontinence care since early morning due to being busy with other tasks. The DON confirmed that incontinence care should be provided every two hours, but the facility's policy lacked specific guidelines for the frequency of incontinence care and checks. This deficiency was part of a complaint investigation.
Inadequate Assessment and Care for Urinary Incontinence and Catheter Use
Penalty
Summary
The facility failed to adequately assess and treat urinary incontinence for Resident #73, who was admitted with multiple diagnoses including osteomyelitis, endocarditis, diabetes, and pressure ulcers. Upon admission, the resident was noted to be incontinent of bladder and bowel, yet there was no comprehensive bladder assessment conducted to identify the type of incontinence. Additionally, there was no plan of care developed to address the resident's incontinence. The resident's records showed a significant number of incontinence episodes, and interviews with the Director of Nursing and Corporate RN confirmed the lack of assessment and care planning. For Resident #57, the facility failed to provide an adequate indication for the use of an indwelling urinary catheter. The resident, who had diagnoses including end-stage renal disease and diabetes, was readmitted with orders for a urinary catheter without documented justification. Medical records, including physician and nurse practitioner assessments, lacked evidence of a valid indication for the catheter's use. Observations during the survey confirmed the presence of the catheter, and interviews with the Director of Nursing and the resident's representative revealed no known reason for its use.
Inadequate Incontinence Care for Resident with Dementia
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident diagnosed with Alzheimer's disease and dementia, who was frequently incontinent with his bladder and always incontinent with his bowel. The care plan for the resident required cleansing of the perineum after each incontinence episode. However, during an observation of incontinence care, a CNA did not follow the proper procedure for cleaning the resident, particularly in handling the uncircumcised penis. The CNA wiped the resident in a downward motion on both sides and brushed down the penis without retracting the foreskin to clean beneath it, as required by the facility's policy. The CNA admitted during an interview that she was trained differently at the facility compared to her aide training, which included cleaning the foreskin and scrotum. The facility's policy for perineal care of a male resident specifies using a washcloth with mild soap, cleaning the urethral meatus if a catheter is present, and washing the penis in a circular motion while retracting the foreskin for uncircumcised residents. The CNA's deviation from this policy contributed to the deficiency in providing proper incontinence care for the resident.
Deficiencies in Indwelling Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care for two residents, leading to deficiencies in accordance with physician orders and care plans. For one resident, there was a lack of adequate indication for the use of an indwelling urinary catheter. The resident was admitted with a Foley catheter, and the Licensed Practical Nurse (LPN) noted urinary retention with neurogenic bladder as the reason for the catheter. However, the Nurse Practitioner (NP) could not find documentation to support this diagnosis, and the diagnosis of neuromuscular dysfunction of the bladder was only added a month after admission. The Director of Nursing confirmed the absence of a facility policy on reasons to maintain a Foley catheter. For another resident, the facility failed to document the output from the Foley catheter as required by the care plan and physician's orders. The treatment records showed missing documentation of catheter output for specific shifts over several days. The Administrator verified the absence of documentation for these dates and times. The facility's policy on urinary catheter care required maintaining a record of the resident's daily output, which was not adhered to in this case.
Inadequate Incontinence Care Provided to Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident who was dependent on staff for toileting and personal hygiene. The resident, who was admitted with diagnoses including a displaced right femur fracture, diabetes mellitus, and unspecified dementia, was observed receiving incontinence care that did not adhere to the facility's policy. During the observation, a CNA used two wet washcloths without a barrier beneath them and without soap or a wash basin. The CNA washed the resident's perineal area and rectal area, where a bowel movement was present, using the same washcloths, and dried the resident with a towel. The CNA did not follow proper procedures for hand washing and glove use, as she only changed gloves once during the process. The facility's policy required the use of perineal wash or a mild cleanser, pat drying, and the application of a protective barrier ointment, which were not observed during the care provided. This deficiency was identified during a complaint investigation and affected one of four residents sampled for activities of daily living.
Inadequate Incontinence Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide necessary incontinence care for Resident #11, who was cognitively impaired and dependent on staff for incontinence management. Resident #11 had a history of cerebral infarction, hemiplegia, aphasia, dementia, and muscle weakness, and was always incontinent of bowel and bladder. The care plan for Resident #11 required incontinence care after each episode, but observations revealed that the resident was found with a soiled brief and saturated bedding, indicating a lack of timely care. The resident's room had a strong foul urine odor, and the resident had moisture-associated skin damage (MASD) to the gluteal fold and bilateral buttocks, which was stable but not improving. Interviews with staff revealed that Resident #11 was particular about who provided her care, allowing only certain CNAs to assist her. CNA #290, who was assigned to Resident #11, had not provided incontinence care since the start of her shift, and there was no evidence that the resident had refused care during that time. The Director of Nursing stated that residents should be checked and changed every two hours, but the Assistant Director of Nursing confirmed that effective interventions were not in place to manage the resident's care preferences. The facility did not provide evidence of incontinence care being refused or performed by night shift staff prior to the morning shift.
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