Federal inspectors issued immediate jeopardy violations to Focused Care at Beechnut on June 28 after discovering that Resident 72, a man with neurogenic bladder and kidney disease, had developed what the urologist later diagnosed as "penoscrotal hypospadias" from prolonged catheter trauma.
The resident told inspectors his catheter "has always been rubbing and pulling on him" and that "his slit grew over time." He described the condition as "very painful."
When inspectors finally observed staff measuring the wound on June 28, they found it stretched 8 centimeters long, 1 centimeter wide, and 0.4 centimeters deep. The area appeared "red and raw." The treatment nurse, measuring the split for the first time, stated she "did not know it was that bad."
Records show staff had been aware of the "opening in the penile area due to prolonged Foley catheter use" since at least April 30. A nurse documented the condition and noted that the nurse practitioner had been notified. Yet the facility's weekly skin assessments from April through June 13 contained no documentation of the penis split.
The facility's own care plan required staff to "ensure Foley was secured via Velcro strap to reduce friction/pulling" every shift. But inspectors repeatedly observed the catheter unsecured, with the Velcro strap placed uselessly on the resident's mid-thigh or knee rather than anchoring the catheter itself.
During one observation on June 27, inspectors watched as certified nursing assistant B provided catheter care without washing her hands before putting on gloves. She cleaned the catheter with wet wipes while the resident's "penis head was slit from the base to the scrotum and was red and raw." When she repositioned the resident to clean a bowel movement, she never changed her contaminated gloves, using the same hands to handle clean supplies and dress the resident.
The nursing assistant later admitted she "forgot to wash her hands and change gloves" and acknowledged that an unsecured catheter "could come out or cause pain."
The facility's breakdown extended beyond basic hygiene and catheter care. Resident 72 had been scheduled for urology consultations multiple times starting in March, but the appointments were repeatedly missed or delayed. Orders for urology consults appeared on March 14 and March 30, with physician notes indicating the need to evaluate hematuria and consider "SPT placement to avoid Foley related hematuria."
The resident finally saw a urologist on June 20 — nearly three months after the initial referral. The urologist's report, which the facility didn't obtain until June 28 when inspectors demanded it, revealed the extent of the damage: "managed with Foley catheter but has caused urethral breakdown now has a penoscrotal hypospadias."
The urologist recommended changing to a suprapubic tube, a surgical alternative that would bypass the damaged urethra entirely.
Records show the facility's medical director was aware of the resident's condition but couldn't recall specifics when interviewed. "If you have to put words in my mouth it would be three weeks," he told inspectors when asked how long the resident had the split, "but he could not say for sure."
The director of nursing, who started at the facility on May 16, said she was unaware that the follow-up system for specialist appointments "was broken." She discovered that nurses had been calling the urologist's office but failing to document their efforts.
The administrator, who began working at the facility on June 3, similarly claimed ignorance of the systemic failures. Both administrators told inspectors they believed the social worker was responsible for managing the appointment system.
During the inspection, staff revealed additional concerning practices. When inspectors observed care for Resident 54, they found nursing assistants placing the catheter drainage bag directly on the resident's bed during care — a practice that risks contamination.
The facility's response to the immediate jeopardy citation included mandatory retraining for all staff on catheter care, skin assessment, and physician notification procedures. The director of nursing provided one-on-one training to the treatment nurse on June 28, focusing on proper wound assessment and care plan updates.
Daily focused rounds by nursing management were implemented for all residents with catheters, specifically to ensure proper securement devices and identify any signs of trauma or irritation.
The social worker received additional training on appointment coordination, including verification of insurance coverage and communication with medical offices to prevent future missed appointments.
Inspectors removed the immediate jeopardy designation on June 30 after the facility demonstrated compliance with corrective measures. However, the facility remained out of compliance at a lower severity level while inspectors monitored the effectiveness of the new systems.
Resident 72's case illustrates the cascading effects of multiple system failures in nursing home care. What began as a routine catheter management issue evolved into a serious medical condition requiring surgical intervention, all while the resident endured months of preventable pain.
The resident, who has moderate cognitive impairment according to facility assessments, relied entirely on staff to recognize, assess, and address his deteriorating condition. That trust was repeatedly violated through inadequate monitoring, poor infection control, and a communication system so dysfunctional that critical specialist appointments were missed for months.
When inspectors interviewed Resident 72 on June 30, he appeared well-groomed and reported his pain level as zero following recent treatment. But he expressed lingering concern about potential infection and wondered aloud "why it took the facility so long to address his catheter."
The urologist's recommendation for a suprapubic tube represents the most invasive solution to a problem that proper catheter securement and timely medical follow-up might have prevented entirely.
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.
