EDMONDS, WA- ALDERCREST HEALTH AND REHAB CENTER

Based on observation, interview and record review, the facility failed to provide appropriate treatment and
services to prevent catheter-associated injury or urinary tract infections for 2 of 5 residents (Residents 1 and
2) with an indwelling urinary catheter (tube for drainage of urine).
The facility failure to provide adequate & timely assessment, close monitoring and timely reporting of
condition changes, and interventions, such as checking for proper placement of a urinary catheter and/or
consideration of all possible causes for reduced/obstructed urine flow through the catheter, contributed to
harm for Resident 1 who developed an acute life threatening medical condition related to catheter
placement/migration. Resident 1 was hospitalized due to the acute medical condition and required surgical
intervention which constituted a situation of an Immediate Jeopardy (IJ).
The failure to monitor for positioning of the urinary catheter drainage bag also placed Resident 2 at risk for
catheter-associated Urinary Tract Infection (CAUTI) and catheter associated injury, as well as risk for
diminished health and quality of life.

A late entry nurse practitioner’s note on 03/18/2021, signed at 7:38 PM, showed the resident had an
excessively swollen penis with a gray/white-colored lesion measuring 2 inches on the penile shaft with
purulent drainage. The note indicated the penis was extremely tender to touch, the suprapubic region (lower
abdomen) was reddened and inflamed, and the resident had a decreased urine output of 100 ml in the Foley
catheter bag. The provider recommended the resident to be immediately sent to the hospital emergency
room (ER) for further evaluation and treatment. The provider also documented that without immediate
treatment, the patient was at high risk for further organ dysfunction and death. The resident was then
transported to the ER for further evaluation.

RESIDENT 2
Resident 2 admitted to the facility on [DATE]. A medical provider progress note, dated 06/26/2020, showed
the resident admitted to the facility with a suprapubic urinary catheter. Review of the resident’s admission
Minimum Data Set (MDS), showed the resident had cognitive impairment and was not able to make her
needs well known.
Review of Resident 2’s care plan, initiated on 08/21/2020, identified the resident with an Alteration in urinary
elimination related to urethral catheter-Urinary retention that cannot be managed medically or surgically.
Interventions were to keep catheter anchored to prevent tension or trauma.
Review of March 2021 nursing progress notes and Treatment Administration Record (TAR) showed no
documentation that nursing staff was monitoring the catheter placement or the placement of the drainage
bag.
During a joint observation and interview on 03/29/2021 at 1:09 PM with Staff E, the resident was lying in bed
uncovered wearing an incontinent garment. A urinary catheter, unanchored and unsecured, lead to a urine
drainage bag on the ground. The resident was restlessly moving her legs. Staff E stated the catheter bag
should not be on the floor because it placed the resident at risk for infection and catheter injury from
displacement of the catheter balloon.
On 04/14/2021 at 10:26 AM, Staff I, Director of Nursing acknowledged the facility was not following the
policies and procedures related to indwelling catheters and catheter related complications. Staff I also stated
review of staff competencies had not been completed since 2018.