Failure to Assess and Manage Indwelling Urinary Catheters and Voiding Trials
Summary
The deficiency involves the facility’s failure to monitor and justify the continued use and removal of indwelling urinary catheters for two residents, and to follow ordered protocols for voiding trials and post-void residual (PVR) monitoring. For one resident with a history of left hip fracture, diabetes mellitus, benign prostatic hyperplasia, and urinary obstruction, the admission MDS and care plan documented the presence of an indwelling catheter and general catheter care tasks, but there was no assessment addressing possible removal of the catheter. Hospital transition orders recommended temporary catheter management per nursing protocol for urinary retention, yet the facility did not document evaluation of the ongoing need for the catheter. During a multidisciplinary care conference with the family, staff reviewed the resident’s care needs but did not address the indwelling catheter or infection risk related to its continued use. Subsequent nursing notes for this resident documented that blood was noted in the catheter because the resident was trying to pull it out, and an outside orthopedic provider later expressed concern that the catheter had remained in place since hospitalization, recommending removal when medically acceptable due to high infection risk and noting the resident had not received the care specifically needed. The facility’s alleged neglect investigation, initiated after the family reported concerns that staff refused to remove the catheter, concluded there was no abuse or neglect but did not address the continued use of the catheter. Staff interviews revealed that LPNs waited for direction from the nurse manager for catheter removal, that the supervising LPN was unsure whether the provider had been contacted about removal for this resident, and that if a provider chose to keep a catheter in place this decision would not be documented. The supervising LPN agreed there was no justification for continued catheter use and acknowledged that a voiding trial was only started on the day of discharge at another facility, and the DON confirmed there was no documentation of assessment for appropriateness of continued catheter use. For a second resident admitted with a lower leg fracture and urinary retention, the care plan documented an indwelling catheter but left the reason for the catheter blank, and the admission assessment noted no factors related to urinary incontinence and no justification for continued catheter use. Provider notes indicated the resident had a UTI and urinary retention in the hospital, had failed a voiding trial, and was started on medication for urinary retention. Later provider notes ordered removal of the catheter and initiation of bedside commode use, with specific orders to scan the bladder every shift for 72 hours, perform straight catheterization if bladder volume exceeded a set threshold, and replace the indwelling catheter after a third failed attempt. The record showed the catheter was removed and that the resident subsequently failed a voiding trial and required reinsertion of an indwelling catheter, but there was no documentation of PVRs during the initial ordered monitoring period. When the catheter was later removed again, there was no corresponding provider order in the record and no PVR monitoring to ensure the resident could tolerate removal. Staff interviews confirmed that PVRs were not done when ordered, that no urology consultation was obtained despite ongoing urinary retention, and that PVR monitoring before discharge was inconsistent. Discharge documentation noted the resident would need catheter replacement upon discharge and later documented difficulty voiding and high PVR with straight catheterization, without mention of post-catheterization care, further PVRs, or urology follow-up.
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.
Foley Catheter Bags Not Emptied as Ordered: Two residents with indwelling Foley catheters had drainage bags observed more than half full, despite orders to empty them every shift or every 4 hours. Staff interviews showed CNAs and nurses were responsible for emptying and reporting output, but the bags had not been emptied as expected and one CNA did not report the output to the nurse.
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.
Foley Catheter Bags Not Emptied as Ordered
Penalty
Summary
The facility failed to ensure appropriate catheter care and treatment for residents with indwelling Foley catheters. Resident #33 was admitted with diagnoses including sepsis, acute kidney failure, and obstructive/reflux uropathy, and her MDS coded her as always incontinent with a BIMS score of 13. Her care plan identified an indwelling Foley catheter for neurogenic bladder and directed staff to position the catheter bag and tubing below bladder level, while the clinical order required Foley catheter care, patency checks, and emptying the bag every shift. On 04/29/2026 at 11:22 a.m., Resident #33’s Foley bag was observed to be 1600 cc out of 2000 ml full. During interviews, CNA A stated she checked the bag at the beginning of her shift and usually emptied it at the end of the shift or when full. CNA B stated she emptied the bag during the night shift but did not remember whether she reported the output to the nurse. RN A and RN B both stated that CNAs and nurses were responsible for emptying the Foley bag, and they indicated that the amount observed meant the night shift did not empty it. The resident stated the Foley catheter was not emptied throughout the night. Resident #28 was admitted with neurogenic bladder, had a BIMS score of 13, was paraplegic, and had an indwelling catheter documented in the MDS. Her care plan stated she was dependent on the catheter for management of neurogenic bladder and included monitoring and reporting for signs and symptoms of UTI and catheter-related discomfort. Her clinical order and MAR directed that the Foley bag be emptied every four hours. On 04/30/2026 at 5:00 p.m., Resident #28’s Foley bag was observed to be 1500 cc out of 2000 cc full. LVN B and LVN C stated that the bag should have been emptied by the earlier shift and that the output had not been reported at shift change. CNA C stated she had emptied the bag once during her shift but did not report the reading to the nurse because she did not know she had to do so.
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.
