Death by Neglect: How Skipped Catheter Care Led to a Resident’s Death at AU Well Care Home of Maryville

IDPH has cited and fined AU Well Care Home of Maryville when a cognitively aware patient with Parkinson’s disease and kidney problems developed an infection and died after his basic catheter care was repeatedly overlooked.

Early warning signs of problems appeared when staff noted the resident was having difficulties with his catheter. Progress notes documented concerning incidents, including one where orange-colored urine was “free flowing on to his clothing and bedding” because the catheter had become detached. The next day, staff observed blood in his urine as he continued to pull at the catheter, yet no significant action was taken to address these issues.

The situation reached a critical point when the resident arrived at the Emergency Room unresponsive and feverish. The ER nurse discovered truly alarming conditions. The catheter bag, which had a maximum capacity of 600 milliliters, was holding twice that amount – 1200 milliliters of what she described as looking like “days old apple cider.” When questioned, the facility claimed they had emptied the catheter that morning, but as the ER nurse noted, “there would be no way the catheter bag would be that backed up if they had completely emptied it at 8:00 AM that morning and arrived at the ER around noon.”

Perhaps most disturbing was the facility’s lack of basic documentation and care planning. According to the Administrator, they “could not find any policies with explicit details pertaining to the steps and procedures of incontinence and catheter care.” The facility had failed to even create a care plan for the patient’s catheter or maintain proper orders for its care.

The facility’s Administrator later admitted to serious shortcomings, stating, “I’m very unhappy with how [the resident] was provided care, I can tell you it has a lot to do with lack of nursing oversight and nursing judgement.” The Emergency Room nurse who cared for him was even more direct, stating that his death “was so preventable and bothered her so much because all the facility had to do was empty his catheter timely which they neglected to do.”

The patient ultimately died from septic shock caused by an E. coli urinary tract infection – a condition that, according to medical professionals involved in his care, could have been prevented with proper catheter maintenance. The Intensive Care Doctor who treated him confirmed that the resident had reported the facility hadn’t changed his catheter for several days before his admission.

This case represents a systematic failure of basic nursing care, where the lack of proper protocols, documentation, and daily attention to a resident’s basic needs resulted in a preventable death. The facility’s own Medical Director admitted he wasn’t even aware of any catheter-related issues until the day the resident was sent to the hospital, highlighting a profound breakdown in communication and oversight.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.