Failure to Assess and Manage Abnormal Catheter Urine Leading to Septic Shock
Summary
The deficiency involves the facility’s failure to ensure that a resident with an indwelling urinary catheter received appropriate assessment, intervention, and catheter management in response to persistent abnormal urine characteristics and signs of possible infection. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an indwelling catheter, colostomy, and feeding tube, and was dependent on staff for all ADLs. Her care plan identified her as having a catheter, being at risk for UTIs, and having frequent UTIs, with specific interventions to monitor urine for color, sediment, odor, amount, and to report abnormalities such as blood-tinged urine, cloudiness, no output, deepening of urine color, and other signs of UTI to the physician. Physician orders directed that the Foley catheter and drainage bag be changed PRN for signs of infection, obstruction, or compromise of the closed system. On one date, an LVN documented that the resident’s catheter was draining blood-tinged urine, that her blood pressure was low, and that the physician was notified, resulting in orders for a UA and IV fluids. The resident later refused IV fluids, and a UA collected showed blood, protein, mucus, and WBC clumps, with blood and protein flagged as critical, but there were no documented follow-up orders or interventions after these results. The NP documented dark orange/red urine and noted a contaminated UA with mixed microbial growth, ordering a repeat UA and labs, and recorded that the resident had refused IV fluids. The NP stated that dark orange urine could be normal if related to minor bleeding from catheter movement but that dark brown/black urine would not be normal and should be reported; she also stated that whenever a UA was ordered, staff were supposed to change the catheter. The electronic record showed the resident’s indwelling catheter was last changed several months earlier, with no documentation of catheter changes, urine color/characteristics, or change in condition from that date through the days immediately preceding the resident’s transfer to the hospital. Multiple staff interviews and video evidence showed that the resident’s urine had been dark brown to black and foul-smelling for weeks without appropriate assessment, documentation, or escalation. CNAs and LVNs reported that the urine appeared reddish, like iced tea, brown/blackish, and had a bad odor for approximately a month or a few weeks, and that they assumed it was normal after it remained that way; several nurses acknowledged they did not assess the catheter or urine every shift and did not consistently document or notify the physician about the worsening color. Video footage provided by the responsible party showed dark/black, opaque urine in the drainage bag on multiple nights, and hospital staff described the catheter on admission as draining purulent, very dark/black urine with foul odor, pus in the tubing, and mold on the catheter balloon and tip, suggesting it had not been changed for a long time. The facility’s own catheter policy required timely and appropriate assessments, ongoing monitoring for catheter-associated UTI, recognition and reporting of complications, and catheter and drainage bag changes based on clinical indications such as infection or obstruction. Despite these requirements and the resident’s known history of frequent UTIs and chronic catheter use, the facility did not assess, intervene, or change the catheter while the resident’s urine remained abnormal over an extended period, culminating in her transfer to the hospital where she was diagnosed with severe sepsis with septic shock likely from a UTI.
Removal Plan
- Performed a 100% audit (DON, ADON, Wound Care Nurse) of residents with catheters to verify catheter placement/securement, urine characteristics, signs/symptoms of UTI, EMR documentation accuracy, and catheter change dates.
- Replaced any urinary catheter immediately (by a licensed nurse) for residents with abnormal findings; notified physician immediately, implemented new orders promptly, and increased monitoring every shift.
- Provided a 1:1 in-service to the LVN who failed to document catheter change on the importance of documenting all care provided (including catheter changes), with progressive discipline up to termination for further infractions.
- Completed an in-service for all licensed nurses and CNAs on catheter care/maintenance, UTI prevention, change-in-condition notification, documentation requirements, and when to notify the physician; staff were not permitted to return to resident care until in-services were completed.
- Implemented DON/designee review of resident changes in condition via SBAR, documentation, and initiated interventions during clinical meetings; addressed issues immediately with the licensed nurse and/or IDT, resident/RP, and physician as necessary; adopted as standard IDT review process for residents with catheters.
- Implemented DON/designee verification of catheter orders and documentation of catheter care and assessments; adopted as standard IDT review process for residents with catheters.
- Conducted visual checks by DON/designee to ensure catheter care is maintained and without abnormalities until 100% compliance is achieved; communicated potential issues to the IDT, resident/RP, and physician.
- Implemented a questionnaire process to validate effectiveness of the urinary catheter care process with licensed nurses, CNAs, and nurse managers; provided immediate re-education if staff could not answer appropriately.
- Ran a physician orders report to check and verify accuracy of any new catheter orders; immediately corrected issues; adopted as standard IDT review process for residents with catheters.
- Clarified and corrected incomplete/incorrect/conflicting catheter orders/documentation immediately when identified by DON/designee; adopted as standard IDT review process for residents with catheters.
- Conducted an impromptu QAPI meeting with the Medical Director to obtain approval of the action plan.
- Reported findings to the QI process and QA committee monthly (Administrator and DON/designee) and addressed any concerns/recommendations immediately.
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 August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.