The resident's urinary catheter hung loose and unsecured, moving freely each time he shifted position. His urine appeared pinkish and cloudy with visible sediment in the tubing.
When inspectors asked the nursing assistant why she kept the same contaminated gloves throughout the entire procedure, she did not respond.
Staff I, a certified nursing assistant who regularly cared for Resident #3, told inspectors the catheter's securing system was "sometimes" attached. When it came loose, she said, "Nurses do that" when asked if she would reattach it herself. She claimed she always reported detached catheters to nursing staff.
The resident contradicted her account. When inspectors asked if nurses had attached the securing device to his thigh, he responded, "No."
A second observation the following day at 1:30 PM revealed the same catheter remained unsecured and dangling. Staff F, a restorative nursing assistant, was providing care during this visit.
The resident also told inspectors that staff members did not wash their hands before providing urinary care.
Licensed Practical Nurse Staff J admitted to inspectors at 2:45 PM that she had not yet provided catheter care to Resident #3 during her shift, which began at 7:00 AM. She planned to complete the care "a few minutes before I go home" at 3:00 PM.
She had not assessed the color or consistency of the resident's urine. "I have not done it yet," she told inspectors.
Treatment records showed staff failed to secure the catheter on September 24 and September 26 during day shifts, despite physician orders requiring the procedure.
The facility's care plan revealed a seven-day delay in initiating catheter care protocols. A physician ordered the urinary catheter for Resident #3 on August 4, but nursing staff did not begin catheter care procedures until August 11.
The care plan also lacked evidence-based practice interventions for urinary catheter management.
On October 7, the first day of the federal inspection, a physician prescribed Cefdinir antibiotic capsules for Resident #3 at 3:08 PM. The 300-milligram capsules were ordered twice daily for seven days to treat a urinary tract infection.
Another licensed practical nurse, Staff B, described the facility's catheter care protocols during an interview. She said catheters should be flushed as ordered and that she followed facility policies for catheter management.
"The urinary catheter care is done by staff, and I must perform them for my assigned residents," she told inspectors.
Staff B said she monitored residents for urinary tract infection symptoms including confusion and complaints of burning. She claimed the facility did not wait for fever to develop before investigating potential infections.
She described monitoring urine color and consistency, encouraging adequate fluid intake, and checking catheters frequently during her shifts.
The inspection findings painted a different picture. Records showed inconsistent catheter securement, delayed care protocols, and contaminated care procedures that likely contributed to Resident #3's infection.
Federal regulations require nursing homes to prevent infections and maintain sanitary conditions during personal care. The facility's failures in basic catheter management created conditions that put the resident at risk for serious complications.
Urinary tract infections in catheterized nursing home residents can lead to sepsis, kidney damage, and death if left untreated. Proper catheter securement prevents trauma to the urethra and reduces infection risk, while hand hygiene and glove changes during care procedures are fundamental infection control measures.
The resident's pinkish, cloudy urine with sediment indicated an active infection requiring immediate antibiotic treatment. The physician's prescription on the inspection's first day suggested the infection had progressed to a point requiring medical intervention.
Resident #3 experienced the consequences of multiple care failures: unsecured medical equipment, contaminated care procedures, delayed assessments, and inadequate monitoring by nursing staff responsible for his daily care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Broward Oaks Nursing and Rehabilitation from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
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