Resident #2 returned from the hospital in early November with a foley catheter. Staff emptied his drainage bag constantly because he drank fluids throughout the day and the bag filled quickly. But the facility's administration record showed no orders for the catheter care he was receiving.
CNA A told inspectors on December 19 that he changed Resident #2's foley catheter bag "just about every hour during the shift." He provided peri care by cleaning the catheter insertion area and tubing throughout each day. When bags leaked, he notified nurses for replacements.
"Resident #2's foley bag would become full very quickly due to the number of fluids that Resident #2 would consume throughout the day," CNA A said.
The aide documented his work in the electronic medical record under a task for incontinent care. But that wasn't where catheter care was supposed to be tracked.
LVN C explained that residents with foley catheters should have orders for cleaning the catheter site and emptying the bag each shift, plus replacing the bag and tubing monthly. Nurses were responsible for entering those orders and documenting catheter care on the administration record.
"Resident #2's foley bag was changed, about every 2 hours because his foley bag would fill up quickly," LVN C said.
The nurse understood why proper documentation mattered. "It was important for a resident to have foley orders so the nurses can document on the resident's care, to show that I did it."
But Resident #2 had no such orders on his administration record.
The Director of Nursing acknowledged the problem when inspectors interviewed her at 12:51 p.m. Any resident admitted with a foley catheter should have had catheter orders on the administration record, she said. Nurses were responsible for obtaining those orders.
The facility had standing orders for foley catheters to be changed monthly and as needed, plus catheter care every shift. The DON said the foley order was entered into the electronic medical record on November 4 but "was not activated on the administration record, for some reason."
Without activated orders, there was no formal record that required catheter care was being completed.
"It was important for the foley orders to be in the administration record so the task could be completed and there would have been a record that the task was completed," the DON said.
The consequences of missing catheter care extend beyond paperwork. "A resident who did not receive foley catheter care could develop an infection," the DON told inspectors.
The facility's own policy, implemented in May 2025, required catheter care every shift and as needed by nursing personnel. Drainage bags should be emptied when half-full or every three to six hours.
Staff had been trained on these requirements recently. An in-service attendance record from November 25 showed 27 staff signatures on training that emphasized "ensure foley catheter care is performed every shift and when completing incontinent care." The training specified that foley catheters should be changed monthly.
The gap between policy and practice created a documentation void. CNA A was providing catheter care hourly and recording it under incontinent care tasks. LVN C was changing bags every two hours. But the administration record contained no orders for the catheter care both staff members were delivering.
Resident #2 remained nonverbal and unable to respond to questions during the inspection. Inspectors observed him being fed a meal by staff while lying in his hospital bed, the foley catheter bag hanging from the side.
The facility knew how to properly manage catheter care. It had written policies. It had conducted recent training. Staff understood the clinical requirements and infection risks.
But somewhere between entering the foley order on November 4 and the December 19 inspection, the order never made it to the administration record where nurses could formally document the care they were providing.
For six weeks, Resident #2 received catheter care that couldn't be officially recorded as completed. His caregivers understood the medical necessity. They knew he could develop an infection without proper catheter maintenance. They provided care every two hours.
None of it appeared on his official treatment record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Antonio West Nursing and Rehabilitation from 2025-12-19 including all violations, facility responses, and corrective action plans.
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