Failure to Provide Ordered Foley and Suprapubic Catheter Care
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services related to urinary catheter care for three residents with indwelling catheters. One resident with a Foley catheter was admitted with urinary retention and neurogenic bladder and had physician orders for monthly Foley catheter changes and as-needed changes. Treatment Administration Records showed the monthly change order documented as not applicable or refused, and an order directing the primary team to determine if the Foley should be exchanged by urology for discolored, cloudy, and blood-tinged urine was signed as completed. However, there was no evidence that urology was contacted or that an appointment was scheduled, and the Foley catheter had not been exchanged since a hospital procedure months earlier. A community complaint later alleged that this resident arrived at the emergency room with a crusted Foley catheter, erosion of the urinary meatus, significant urinary retention, and foul-smelling urine. The deficiency also includes failure to follow physician orders for suprapubic (SP) catheter exchanges for a second resident with external genitalia, head, and neck malignancies. This resident had a care plan requiring SP catheter changes per physician orders and an order to call and set up an appointment with urology for an SP catheter exchange, which was documented as completed daily on the Treatment Administration Records. A continuity of care document showed that urology had exchanged the SP catheter and indicated that the next SP exchange was due in four weeks at the facility. Record review did not show any evidence that the SP catheter had been exchanged since that urology visit, despite the nurse practitioner’s expectation that the exchange would occur in the facility if not done by urology and the ADNS’s statement that nursing staff were competent to perform SP tube exchanges. For a third resident with a flaccid neuropathic bladder and an SP catheter, the care plan required SP catheter changes per physician orders, and an order specified that SP catheter exchanges were to be completed at urology. A continuity of care document showed that urology had exchanged the SP catheter and scheduled a follow-up appointment for an annual check-up and SP catheter exchange. The urology receptionist reported that the resident did not attend the scheduled follow-up appointment and had not been seen since the prior exchange. The ADNS was unable to provide evidence that the resident had any urology appointments after that date or that the SP catheter had been exchanged according to the physician’s order.
Penalty
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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.
A resident with cognitive impairment and a history of urinary retention was discharged from the hospital with an indwelling catheter and orders for catheter care. After a urology visit where the catheter was removed and the resident passed a voiding trial, facility staff did not obtain or enter updated orders, left prior catheter-care orders active, and later documented providing catheter care even though the catheter had been removed. At some point, the catheter was reinserted without documented physician orders or a comprehensive assessment, and staff inconsistently monitored and recorded urinary output, with only two documented outputs over nearly two weeks. A later order to remove the catheter and discontinue related orders was not carried out. The resident subsequently developed hypotension and abnormal drainage with pus and blood from the catheter, and hospital evaluation revealed a severely distended bladder, hydronephrosis, and a malpositioned Foley catheter balloon in the urethra, with diagnoses including UTI, sepsis, and acute kidney injury attributed to catheter-related obstruction.
A resident with chronic kidney disease, vascular dementia, and frequent bowel/bladder incontinence reported dysuria, and a CNP ordered a UA with C&S. The initial urine specimen was picked up by the lab but later discarded, and there was no documentation of when the facility was notified or whether symptoms persisted. A repeat urine sample was collected and the culture later showed bacterial growth susceptible to antibiotics, yet the resident’s urinary symptoms, potential UTI, and lab results were not addressed in progress notes for an extended period, and antibiotics were only ordered after the positive culture was finally followed up. The resident’s care plan did not address UTI risk or recurrent UTIs, and the facility lacked UTI-related policies.
A resident with recurrent UTIs and multiple comorbidities was ordered nitrofurantoin (Macrobid) 100 mg twice daily for seven days for dysuria due to UTI, with instructions not to start the antibiotic until after a urine specimen was collected. The MAR and progress notes show the first scheduled dose was delayed, several subsequent doses were missed, and the resident ultimately received only 10 of 14 ordered doses, with some doses given before the urine culture was obtained. Attempts to collect urine were delayed or contaminated, and there was no documentation that the NP was notified of the culture delays, early antibiotic administration, or incomplete course of therapy, despite facility policy requiring medications to be administered as ordered.
Two residents did not receive timely bladder-related care, including delayed assessment and treatment of UTI symptoms and prolonged response to incontinence needs. One resident with cognitive and physical impairments, fully dependent for ADLs and incontinent of bowel and bladder, exhibited agitation, hallucinations, altered mental status, and dysuria, yet a physician-ordered urine dip was not obtained as scheduled, and a urine specimen was not collected and sent for testing until six days after symptoms were noted, despite later confirmation by an RN and the resident’s family that UTI signs were present. Another resident with intact cognition, a colostomy, spinal stenosis, and urinary incontinence, care planned for assisted toileting and frequent brief changes, activated the call light due to being wet but waited 41 minutes before a CNA responded; the brief was found full of urine, and both the CNA and DON acknowledged the delay was excessive.
A resident with quadriplegia and neurogenic bladder, dependent on staff for toileting, had a care plan and physician order for a 12F/10 cc Mitrofanoff catheter to be changed monthly. Record review showed no documented catheter change for the month in question, and progress notes did not mention any catheter changes. During observation, an LPN verified that the resident instead had a 14F/10 cc catheter in place and was unable to state how long the incorrect catheter had been used.
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.
Failure to Follow Catheter Orders and Monitor Output Resulting in Catheter-Related Harm
Penalty
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.
Failure to Timely Address UTI and Care Plan Recurrent Infections
Penalty
Summary
The facility failed to timely address a resident’s urinary tract infection (UTI) and to provide appropriate care for bowel/bladder continence and incontinence, catheter care, and UTI prevention. The resident was admitted with multiple diagnoses including chronic kidney disease, osteoarthritis, cognitive communication deficit, adult failure to thrive, delirium, and vascular dementia, and was frequently incontinent of bowel and bladder with moderately impaired cognition. On 03/03/26, the resident complained of pain with urination, and the on-call nurse practitioner ordered a urine specimen for urinalysis with culture and sensitivity. A progress note on 03/04/26 documented that the CNP evaluated the resident for dysuria, noted a history of recurrent UTIs, and that a urinalysis was pending; another note that morning stated the urine had been picked up by the lab. A urinalysis dated 03/04/26 showed the urine was collected and results were pending. From 03/04/26 to 03/15/26, progress notes did not address the resident’s potential UTI, urinary symptoms, or laboratory results. Documentation later showed that urine was collected again on 03/09/26, with culture results reported on 03/13/26 identifying bacteria susceptible to certain antibiotics, but treatment was not initiated until 03/16/26 when the CNP followed up on the positive culture and ongoing dysuria and ordered antibiotics. Interviews revealed the lab had discarded the 03/04/26 urine specimen and that there was no documentation of when the facility was notified, nor of whether the resident continued to have symptoms during that period. The CNP reported multiple issues with the lab, including reports that samples would not be run, and confirmed this occurred in this case. The resident’s care plan did not address her risk for UTIs or her recurrent UTIs, and the facility did not have policies related to UTIs. A Regional MDS staff member verified that the resident’s recurrent UTIs should have been addressed in the plan of care.
Failure to Administer Ordered Antibiotic Regimen for UTI as Prescribed
Penalty
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.
Delayed UTI Management and Incontinence Care Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and treatment for a resident with signs and symptoms of a urinary tract infection (UTI). One resident with cognitive impairment, severe physical impairment, and total dependence for ADLs was care planned for bowel and bladder incontinence with interventions to keep the skin clean and dry. Progress notes documented that the resident exhibited behavioral changes, including agitation, hallucinations, altered mental status, and complaints of burning pain with urination. A physician order was obtained to perform a urine dip and notify the physician, but the urine dip ordered on 12/16/25 was not obtained as scheduled. Subsequent documentation showed that the urine dip was not actually completed until several days later, when the resident was straight catheterized and a urine dip revealed positive nitrites, leukocytes, and blood, consistent with a UTI. An antibiotic was then started, and a UA with culture and sensitivity was ordered. The unit manager RN later confirmed that the resident had signs and symptoms of a UTI on 12/15/25 and that the urine sample was not collected and sent out until six days later, stating that the specimen should have been collected and sent immediately. The resident’s daughter reported that in December the resident had UTI symptoms and was not started on an antibiotic for six days, and that staff had told her the resident was at baseline and did not have a UTI. The deficiency also includes failure to provide timely incontinence care for another resident with intact cognition, a colostomy, spinal stenosis, weakness, and inability to control bowel or bladder. This resident’s care plan called for staff assistance with toileting, frequent checking and changing of briefs, and provision of toileting hygiene with brief changes. Surveyors observed the resident’s call light on and, upon interview, the resident stated he had turned it on because he was wet and needed changing and that staff did not always respond timely. The call light remained on for 41 minutes before a CNA entered to provide incontinence care, at which time the resident’s brief was full of urine. The CNA and the DON both acknowledged that 41 minutes was too long for a call light to remain unanswered for a resident needing staff assistance.
Incorrect Urinary Catheter Size Used Contrary to Physician Order
Penalty
Summary
The facility failed to ensure a resident with an indwelling urinary catheter received the correct catheter size as ordered by the physician and outlined in the care plan. The resident was admitted with diagnoses including quadriplegia and neuromuscular dysfunction of the bladder, and had intact cognition but required total staff assistance for bed mobility, transfers, and toileting. The resident’s care plan specified a Mitrofanoff catheter 12 French (F) with a 10 cubic centimeter (cc) balloon to be changed every 30 days, and the physician’s order directed that this 12F/10 cc Mitrofanoff catheter be changed on the 28th of each month. Review of the medical record showed no documentation on the medication administration record of any urinary catheter change for the resident in the month of March prior to the observation of the incorrect catheter. Progress notes from 03/01/25 to 03/22/25 were also silent regarding any catheter changes. During an observation with an LPN on 03/17/26, the resident was found to have a 14F/10 cc catheter in place instead of the ordered 12F/10 cc catheter. The LPN confirmed the catheter size was incorrect and stated that the catheter should be 12F/10 cc, but did not know how long the 14F/10 cc catheter had been in place.
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