HOUSTON, TX - Federal health inspectors declared an immediate jeopardy situation at Focused Care at Beechnut after discovering staff failed to properly secure and monitor a resident's urinary catheter, resulting in a painful injury that went unaddressed for an extended period.
Critical Catheter Care Breakdown
The most serious violation discovered during the July 2, 2024 inspection involved a resident identified as Resident #72, who developed a significant injury to his penis due to improper catheter management. The inspection revealed that staff had failed to secure the catheter tubing with a leg strap, allowing it to pull against sensitive tissue. This oversight resulted in a slit extending from the base of the resident's penis to his scrotum, which was documented as "red and raw" during the survey.
The resident, who had been admitted with diagnoses including hemiplegia following a stroke, chronic kidney disease, and neurogenic bladder dysfunction, required an indwelling catheter for bladder management. Medical records indicated he had been using this catheter since at least January 2024, yet basic protocols for securing the device were not consistently followed.
When surveyors interviewed Resident #72, he stated the catheter had been "pulling and rubbing on his skin" and described the injury as "very painful." He expressed frustration about how long it took the facility to address his catheter issues, questioning why basic care measures had been neglected.
Delayed Medical Response and Documentation Failures
Beyond the initial failure to prevent the injury, inspection records revealed significant gaps in how staff responded once the problem became apparent. The facility's treatment nurse failed to conduct proper weekly skin assessments that would have detected and measured the injury earlier. When the wound was finally documented, staff did not immediately update the resident's care plan to reflect the new skin condition or modify interventions to prevent further damage.
The inspection also uncovered that despite the visible injury, no pain assessments were conducted until surveyors questioned staff about the resident's condition. Pain management represents a fundamental aspect of nursing care, and the failure to assess and address discomfort from an obvious wound indicates systemic gaps in clinical oversight.
Indwelling catheters require meticulous attention to prevent complications including urinary tract infections, urethral trauma, and tissue damage. Standard nursing protocols mandate that catheter tubing be secured to the patient's thigh using a specialized strap or device, preventing tension on the urethra while allowing enough slack for movement. The tubing must be positioned to avoid kinks and ensure proper drainage, with the collection bag maintained below bladder level to prevent backflow of urine.
When these protocols are not followed, the weight of the drainage tubing can create constant pulling force against delicate urethral tissue. Over time, this mechanical stress can cause pressure ulcers, tissue tears, and in severe cases, urethral erosion. The resulting wounds are not only painful but create entry points for bacteria, significantly increasing infection risk in patients who already face elevated vulnerability due to the catheter itself.
Pattern of Inadequate Specialist Follow-Up
The inspection identified a second resident, #74, whose case revealed broader systemic problems with medical appointment management and follow-up care. This resident had been seen by a urologist on June 20, 2024, but the facility failed to obtain documentation from that visit or ensure that recommended treatments were implemented.
According to inspection records, the urologist indicated he would send paperwork following the appointment, but the facility did not follow up when these documents failed to arrive. Nursing staff reportedly contacted the specialist's office but did not document these calls, leaving no record of their attempts to obtain critical medical information. This gap in communication meant that any recommendations, test results, or treatment modifications from the specialist visit were never incorporated into the resident's care plan.
The administrator and director of nursing acknowledged during interviews that they were unaware the follow-up system was not functioning properly. They described the existing process as "broken" and admitted that the lack of proper follow-up "could have caused a delay in care" for residents requiring specialist intervention.
Coordination with specialist physicians represents an essential component of nursing facility care, particularly for residents with complex medical conditions requiring urology, cardiology, or other specialty services. When facilities fail to obtain and act upon specialist recommendations, residents may miss critical interventions including medication adjustments, surgical procedures, or diagnostic tests that could prevent deterioration or manage chronic conditions effectively.
The absence of documented communication attempts compounds this problem by making it impossible to determine whether delays resulted from specialist office failures or facility negligence. Proper documentation creates accountability and provides a clear timeline for quality improvement efforts.
Infection Control Violations During Personal Care
Surveyors directly observed serious infection control breaches during the provision of catheter and incontinence care to Resident #72. On June 27, 2024, inspectors watched as a certified nursing assistant performed personal care without following basic hygiene protocols designed to prevent cross-contamination.
The CNA failed to wash her hands before putting on gloves at the start of the care procedure. During the care provision, she cleaned the catheter, repositioned the resident, and cleaned fecal matter without changing gloves between these tasks. Most concerning, she used the same contaminated gloves to handle a clean brief, placed it on the resident, and completed dressing without ever changing gloves or sanitizing her hands.
When interviewed immediately after this observation, the medication aide who assisted acknowledged that "CNA did a good job only she did not change gloves and she used the same gloves throughout the procedure." The CNA herself admitted she "forgot to wash her hands and change gloves" despite having completed skills competency assessments when hired one year earlier.
The human body harbors distinct bacterial populations in different areas, with the gastrointestinal tract containing organisms that can cause serious infections if introduced to the urinary tract or open wounds. This is why infection control protocols mandate specific sequences: clean procedures before dirty ones, hand hygiene between different body sites, and glove changes when moving from contaminated to clean areas.
Failing to change gloves after cleaning fecal matter and then handling a catheter creates direct risk for introducing intestinal bacteria into the urinary system. For a resident with an existing urethral wound, this risk escalates significantly as bacteria can enter broken skin and cause local infection or potentially spread to the bloodstream.
Environmental Infection Control Concerns
The inspection also documented infection control problems in the facility's laundry operations. Surveyors found personal items including food containers, eating utensils, and grooming supplies placed directly on the table used for folding clean linens. Clean clothing and linens were stored on the floor in both clean and dirty sections of the laundry room, while some clean items were stored in the dirty section of the facility.
The hand-washing soap dispenser in the laundry's dirty section had been broken for at least two days, forcing the laundry aide to leave the work area and use a hallway restroom to wash her hands after handling soiled linens. Both the laundry aide and housekeeping director acknowledged these practices violated infection control principles but indicated they continued due to space limitations and equipment failures.
Proper laundry handling serves as a critical infection prevention measure in healthcare facilities. Clean linens that contact contaminated surfaces, floors, or unwashed personal items can harbor pathogens and transfer them to residents during bed changes or bathing. When staff must leave the laundry area with contaminated hands to find working sinks, they risk spreading organisms throughout common areas while simultaneously potentially re-contaminating their hands before returning to handle clean items.
Facility Response and Corrective Actions
Upon notification of the immediate jeopardy finding on June 28, 2024, facility leadership implemented several corrective measures. Staff conducted assessments of all residents with urinary catheters to verify proper securing with leg straps and check for any signs of tissue damage. The treatment nurse received individual training on comprehensive skin assessment, documentation requirements, and physician notification protocols.
The facility provided in-service education to all nursing staff on proper catheter securing techniques and the importance of reporting trauma or irritation. Leadership established daily focused rounds specifically for residents with catheters to monitor for proper equipment placement and early signs of complications. The social worker received training on appointment scheduling and follow-up procedures, while nursing staff were assigned responsibility for ensuring documentation returns from specialist visits.
Surveyors verified these immediate actions had been implemented and removed the immediate jeopardy designation on June 30, 2024, though the facility remained cited for the violations at a lower severity level pending evaluation of whether the new systems would prove effective long-term.
Additional Issues Identified
The inspection documented additional concerns beyond the major violations. The facility's infection control program showed gaps in monitoring staff compliance with basic hygiene practices during direct care provision. Equipment maintenance issues, including the broken soap dispenser, had not been promptly addressed despite being reported. Storage space limitations in the laundry contributed to improper handling of clean linens, though these circumstances did not excuse the infection control breaches. Documentation practices showed inconsistencies, with some staff failing to record important communications with physicians' offices and specialist providers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Beechnut from 2024-07-02 including all violations, facility responses, and corrective action plans.
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