HOUSTON, TX - Focused Care At Beechnut received an immediate jeopardy citation from federal inspectors in July 2024 after failing to provide timely urological treatment to a resident who developed a significant catheter-related injury that went unaddressed for months.
Critical Catheter Care Failures Lead to Severe Injury
The most serious violation involved a 58-year-old male resident with neurogenic bladder who relied on an indwelling catheter for urination. Inspectors found that facility staff failed to properly secure the catheter and delayed necessary specialist care, resulting in an 8-centimeter split in the resident's penis that measured 1 centimeter wide and 0.4 centimeters deep.
The resident had been scheduled for urology consultations multiple times beginning in March 2024 due to blood in his urine, but these appointments were repeatedly missed or delayed due to administrative failures. When staff finally identified the penile split in April 2024, they failed to measure it, update his care plan, or ensure immediate physician notification.
Records show the resident reported that "the foley catheter has always been rubbing and pulling on him and his slit grew over time" and that "it was very painful." Despite these complaints, the facility's response was inadequate and delayed.
The treatment nurse admitted during the inspection that she had noticed the split months earlier but had never measured it. When finally measured during the July inspection, she stated "she did not know it was that bad and it was her first time measuring it."
Medical Consequences of Improper Catheter Management
Indwelling catheters require careful management to prevent serious complications. When catheters are not properly secured with leg straps or other devices, they can cause mechanical trauma to the urethra and surrounding tissues. This friction and pulling can lead to urethral erosion, bleeding, and in severe cases, complete urethral breakdown.
The resident's condition - described in urological records as "penoscrotal hypospadias due to urethral breakdown" - represents a serious complication where the normal urethral opening is disrupted. This condition typically requires surgical intervention and can lead to permanent functional impairment if not promptly addressed.
Medical standards require that residents with indwelling catheters receive proper catheter care every shift, including verification that securement devices are in place and functioning. Regular assessment for signs of trauma, irritation, or infection is essential to prevent complications that can become life-threatening.
Infection Control Violations During Personal Care
Inspectors observed significant infection control breaches during catheter and incontinence care. A certified nursing assistant was observed providing care to the injured resident without following proper hand hygiene protocols. The CNA failed to wash her hands before putting on gloves and did not change gloves when transitioning from cleaning the resident's anal area to handling clean supplies.
These violations create serious risks for healthcare-associated infections, particularly urinary tract infections in catheter-dependent residents. Proper infection control requires hand hygiene before and after each patient contact, and glove changes when moving from contaminated to clean areas during care procedures.
The facility's Director of Nursing acknowledged that "not washing the hands, not changing the gloves, and not sanitizing the hands in between changing of gloves could result to cross contamination and infection."
Breakdown in Specialist Appointment System
The inspection revealed systematic failures in the facility's process for managing specialist appointments. The resident was originally scheduled for urology consultations in March 2024, but these appointments were missed due to the urologist's office relocating without the facility's knowledge.
A May 23, 2024 appointment was also missed, and facility staff failed to follow up promptly to reschedule or notify the physician of the delay. The resident did not receive urological evaluation until June 20, 2024 - nearly three months after the initial referral.
The facility's social worker, who was responsible for coordinating appointments, acknowledged gaps in the system for tracking specialist visits and ensuring proper follow-up. The breakdown in communication meant that critical medical information from specialist visits was not being properly documented or incorporated into residents' care plans.
Inadequate Care Planning for High-Risk Medications
Inspectors also found that the facility failed to develop appropriate care plans for residents receiving anticoagulant medications. One resident who was prescribed Apixaban, a blood-thinning medication, had no care plan addressing the special monitoring and precautions required for anticoagulant therapy.
Anticoagulants require careful monitoring for bleeding complications, drug interactions, and fall risks. Facilities must have protocols for regular assessment of residents on these medications, including monitoring for signs of bleeding, ensuring proper dosing, and coordinating with physicians for laboratory monitoring when indicated.
The MDS coordinator acknowledged that the resident should have had a care plan for anticoagulant use, noting that "the care plan is important because it showed how to provide care to a resident."
Safety Hazards in Resident Rooms
Additional violations included improper storage of potentially dangerous items in resident rooms. Inspectors found an unsupervised disposable razor and multiple bottles of body wash with warning labels in the room of a resident with mild cognitive impairment who required supervision for personal hygiene activities.
The body wash bottles displayed warnings stating "Keep out of reach of children" and "If swallowed get medical help or contact the Poison Control Center right away." These items posed ingestion risks and the razor created potential for injury, particularly given that other residents with dementia could access the room.
Industry standards require that potentially hazardous personal items be properly supervised or secured, especially in environments where residents with cognitive impairment may have access to them.
Additional Issues Identified
The inspection also documented violations related to bed care management, where nursing assistants were observed placing catheter drainage bags directly on residents' beds during care procedures, creating contamination risks. Proper infection control protocols require that drainage bags remain below the level of the bladder and never be placed on beds or other surfaces that could introduce bacteria into the urinary system.
The immediate jeopardy citation was removed after the facility implemented corrective measures, including staff retraining on catheter care, appointment coordination systems, and infection control procedures. However, the facility remained under enhanced monitoring to ensure the effectiveness of these corrections.
The violations at Focused Care At Beechnut highlight the complex medical needs of nursing home residents and the critical importance of systematic approaches to clinical care, communication with healthcare providers, and staff competency in specialized procedures like catheter management.
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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