WESTFIELD, MA - An inspection at Westfield Gardens Nursing and Rehab uncovered a violation where facility staff failed to notify a physician after using medical equipment that differed from doctor's orders, potentially putting a resident at risk for complications.
Catheter Size Discrepancy Goes Unreported
The most significant violation identified during the January 15, 2025 inspection involved a resident who required a urinary catheter for medical management. The facility's physician had specifically ordered a 16 French Foley catheter with a 10cc balloon for the resident's urinary retention condition. However, nursing staff instead inserted a catheter with a 5cc balloon - half the size ordered by the doctor.
The discrepancy occurred on January 1, 2025, when the resident's catheter required changing. According to the inspection report, Nurse #7, who performed the catheter insertion, stated she "filled the balloon to 5cc's because she filled it until she felt that the catheter was secure" and wanted to ensure the resident's comfort. The nurse indicated there had been no apparent issues with the differently-sized catheter.
However, the facility's own policy clearly states that staff must "promptly notify the resident, his or her Attending Physician, and representative of change in the resident's medical/mental condition and/or status" and requires notification when there is a "need to alter the resident's medical treatment significantly."
Medical Significance of Catheter Specifications
The size specifications for urinary catheters are not arbitrary measurements - they serve critical medical functions. The French size (16 Fr in this case) refers to the catheter's diameter, while the balloon size (measured in cubic centimeters) determines how securely the device remains positioned in the bladder.
When physicians order specific catheter dimensions, they consider multiple factors including the patient's anatomy, medical condition, and risk factors. A balloon that is too small may not provide adequate retention, leading to catheter dislodgement. Conversely, an oversized balloon can cause discomfort, bladder irritation, or difficulty with removal.
For residents with conditions like chronic kidney disease and urinary retention - as documented for this patient - proper catheter function is essential for preventing serious complications including urinary tract infections, kidney damage, and acute urinary retention episodes.
Lack of Available Equipment Compounds Problem
The inspection revealed an additional concern regarding the facility's catheter inventory. When investigators examined the available catheters with nursing staff, they discovered that while 16 French catheters were in stock, they only had versions with 30cc balloons - three times larger than what the physician had ordered.
Nurse #5 noted during the inspection that "a 30cc balloon would be too big and most likely uncomfortable for the Resident." This inventory gap suggests the facility lacked the specifically ordered equipment, yet staff proceeded with an alternative size without consulting the physician or updating the medical orders.
The Director of Nursing told inspectors she was unaware that the correctly-sized catheter was unavailable and that this was "the first she was hearing of it." She acknowledged that when staff first identified they did not have the correct catheter size, "the Physician, the PA, and herself should have been notified so that they could further assess the issue."
Potential Health Consequences
The physician assistant responsible for the resident's care was unaware that a different catheter size had been used. During the inspection interview, the PA explained several risks associated with using incorrectly-sized catheter balloons, including urinary leakage, skin irritation and breakdown due to urinary leakage, and possible discomfort.
Perhaps most concerning, the Director of Nursing identified that using a smaller balloon "could put the Resident at risk for the Foley Catheter becoming dislodged." Catheter dislodgement can lead to serious complications requiring emergency medical intervention, particularly for residents with complex urological conditions.
For elderly residents in long-term care, urinary catheter management is a critical aspect of medical care. Improper catheter function can result in urinary tract infections, which are among the most common healthcare-associated infections in nursing homes and can lead to sepsis or other life-threatening complications in vulnerable populations.
Communication Breakdown in Medical Care
This violation highlights a fundamental breakdown in the communication chain between nursing staff and physicians. The facility's policy specifically requires notification when medical treatment is altered significantly, yet this did not occur despite the catheter size change representing a 50% reduction in balloon size from the physician's order.
The physician assistant noted during the inspection that the resident's catheter was changed monthly and she had "never been notified that the facility did not have the correct sized Foley Catheter in stock." She emphasized that she "would expect the facility staff to notify her about this concern."
This lack of communication prevented the physician from making an informed decision about whether the alternative catheter size was appropriate for the resident's specific medical needs and risk factors. It also prevented any necessary adjustments to the care plan or monitoring protocols that might have been warranted with the equipment change.
Medical Standards and Best Practices
Standard medical practice requires that any deviation from physician orders be communicated to the prescribing provider, documented appropriately, and authorized through proper channels. When ordered medical equipment is unavailable, healthcare facilities should contact the physician to discuss alternatives rather than making unilateral substitutions.
Proper catheter management in long-term care settings involves not only following specific sizing orders but also maintaining appropriate inventory levels, training staff on proper insertion techniques, and establishing clear protocols for equipment substitutions. The facility should have systems in place to ensure that when ordered medical supplies are unavailable, alternative arrangements are made with physician oversight.
Additional Issues Identified
Beyond the primary catheter-related violation, the inspection revealed concerning gaps in the facility's medical equipment inventory management and staff communication protocols. The discovery that only oversized catheters were available in stock suggests inadequate planning for residents' specific medical needs.
The incident also highlighted potential deficiencies in staff training regarding when physician notification is required and how to properly document medical equipment substitutions. The facility's own policies were clear about notification requirements, yet staff failed to follow these established protocols.
For the complete details of all violations identified during this inspection, readers should review the full CMS inspection report available through official channels.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westfield Gardens Nursing and Rehab from 2025-01-15 including all violations, facility responses, and corrective action plans.
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