Medicalodges Coffeyville: Catheter Care Failures - KS

The incident at Medicalodges Coffeyville on Midland occurred during a federal inspection in April, when investigators documented multiple failures in basic catheter care that put residents at risk for urinary tract infections.

Resident 59 has Alzheimer's disease, chronic kidney disease, and an enlarged prostate that interferes with normal urination. His care plan specifically called for a catheter with a "Stat-lock" securement device to prevent tugging and potential removal, along with monitoring of catheter output every shift.

But on April 6 at 10:00 AM, inspectors watched as the 83-year-old man moved slowly up the hallway in his wheelchair, unaware that urine was streaming steadily from his overfilled catheter bag onto the floor. Less than two minutes later, a male housekeeper arrived with a wet mop, stating matter-of-factly, "I know who this belongs to."

The facility's own care plan, updated in February 2025, emphasized the importance of the Stat-lock device "to hold the catheter in place and reduce tugging." The plan also directed staff to encourage increased fluid intake to reduce constipation, making proper catheter management even more critical.

Yet when inspectors observed catheter care two days later, they found Resident 59 had no Stat-lock securing his catheter tubing to his thigh. The certified nursing assistant performing the care explained that they don't use the devices "because he just takes them off."

This directly contradicted the facility's licensed nurse, who told inspectors during an interview that "all catheterized residents should have a stat lock on their leg." She confirmed the facility had four cases of the devices in stock.

The administrative nurse later acknowledged that facility expectations were "to have the stat lock on the resident unless he cannot tolerate it, which should be documented in the Care Plan." No such documentation existed for Resident 59.

The catheter bag overflow wasn't an isolated incident. On April 7 at 3:42 PM, inspectors found Resident 59 sitting patiently in the dining room with a "full, round catheter bag" hanging under his wheelchair. They had to notify nursing staff behind the desk about the situation.

Staff told inspectors they "typically empty the catheter bags at the end of their shift." But catheter bags should be emptied when they become one-half to two-thirds full to prevent backflow that can cause infections. Allowing bags to fill completely before emptying creates exactly the kind of overflow situation inspectors witnessed.

During the April 8 observation of actual catheter care, staff did follow proper procedures for cleaning around the insertion site and checking for defects or skin issues. They measured and documented the urine output before discarding it. But the fundamental safety measures — securing the catheter and preventing overflow — remained absent.

Resident 59's medical history made proper catheter care particularly crucial. His diagnoses included obstructive uropathy, a condition where urine flow is blocked, and neurogenic bladder, where nerve damage affects bladder control. His care plan specifically noted the catheter was necessary "to help prevent skin breakdown and risk of UTI."

The Brief Interview of Mental Status score of 13 indicated Resident 59 had minimally impaired cognition, meaning he retained some awareness of his surroundings despite the Alzheimer's diagnosis. His functional assessment documented the need for staff assistance with activities of daily living due to "physical limitations and decreased safety awareness."

When inspectors asked about policies governing catheter care, they discovered the facility had none. The administrative nurse stated on April 9 that "the facility did not have a policy for catheter care and followed the standards of practice."

But the standards of practice clearly weren't being followed. Professional guidelines emphasize that indwelling catheters must be secured to prevent movement that can cause trauma to the urethra or bladder. They also require regular emptying to prevent the kind of overflow that creates infection risk and dignity issues.

The inspection found these failures affected few residents but created minimal harm or potential for actual harm. However, catheter-associated urinary tract infections are among the most common healthcare-associated infections, particularly dangerous for elderly residents with compromised immune systems.

Resident 59's complex medical conditions — including atrial fibrillation causing irregular heartbeat and stage three chronic kidney disease — made him particularly vulnerable to complications from improper catheter care. His enlarged prostate already put him at higher risk for urinary tract infections.

The facility's approach of removing Stat-locks because the resident "just takes them off" ignored alternative securing methods and proper documentation requirements. If a resident cannot tolerate standard securement devices, care plans should reflect alternative approaches, not abandonment of safety protocols.

The housekeeper's casual familiarity with cleaning up catheter overflow suggested this was a recurring problem, not an isolated incident during the inspection period.

Federal inspectors documented their findings as part of a broader review of the facility's catheter care practices, noting the failure to ensure adequate care within accepted standards of practice.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Medicalodges Coffeyville On Midland from 2026-04-09 including all violations, facility responses, and corrective action plans.

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