HOLDEN, MA - A federal inspection at Holden Rehabilitation & Nursing Center completed on February 13, 2025, identified deficiencies in catheter care and behavioral health services, including a resident who received an incorrectly sized urinary catheter and another who waited approximately six months for an ordered psychiatric evaluation.
Incorrect Catheter Size Placed in Resident
Surveyors documented that the facility failed to ensure proper catheter care for a resident with multiple sclerosis, quadriplegia, and neurogenic bladder who had been at the facility since September 2023.
The resident's physician orders specified a 20 French urinary catheter with a 10 milliliter balloon, to be changed every three months or as needed for blockage or leakage. According to treatment records, when the resident's catheter became blocked on February 1, 2025, nursing staff replaced it—but used the wrong equipment.
During a direct observation on February 13, 2025, surveyors and the Unit Manager discovered that the resident actually had a catheter with a 30 milliliter balloon in place rather than the ordered 10 milliliter balloon. Surveyors also noted a red-colored substance on a towel near the resident's leg.
The Unit Manager acknowledged the discrepancy, stating that "the size of the catheter and balloon should reflect what was ordered by the Physician and it did not." She further explained that having a larger balloon size can cause irritation and increase the chances of bleeding.
The catheter balloon holds sterile water and anchors the catheter inside the bladder. A balloon three times larger than prescribed creates significantly more pressure on the bladder neck and urethral tissues. For a resident with neurogenic bladder—a condition where nerve damage impairs bladder function—this increased pressure poses particular risks, as such patients may have reduced sensation and be unable to report discomfort that would otherwise alert staff to problems.
Supply Management Breakdown
The investigation revealed systemic issues with the facility's medical supply management. Central Supply Staff informed surveyors that the facility did not have the correctly sized catheters in stock until they were delivered on the day of the inspection—12 days after the catheter was changed with incorrect equipment.
When asked how long the facility had been without the proper supplies, Central Supply Staff could not provide documentation. He explained that he orders supplies based on lists created by nursing staff on each unit.
The facility's Nurse Practitioner told surveyors that nurses typically call her when they lack the correct catheter equipment and need to change sizing. In such cases, she said, an order should be written to reflect the new catheter balloon size—but this documentation was never completed for this resident.
The Director of Nursing acknowledged during the inspection that "the facility should have supply of the correct size urinary catheters for all the residents who needed them."
The Unit Manager confirmed there was no documented evidence that the wrong balloon size had been placed until surveyors discovered the error during their observation, meaning the resident had the incorrectly sized equipment for nearly two weeks without facility staff identifying the problem.
Six-Month Delay in Psychiatric Evaluation
The inspection identified a more prolonged failure involving behavioral health services for a resident admitted in May 2022 with diagnoses including Major Depressive Disorder and mild cognitive impairment.
According to facility records, the resident underwent a Psychotherapy Evaluation on November 3, 2023, during which they reported that "someone was messing with him/her through the phone and from the hallway, calling his/her name." The psychotherapist recommended ongoing counseling to address negative and repetitive thoughts, and the resident consented to treatment.
However, no psychotherapy sessions were ever provided following this evaluation. The Behavioral Health Manager later attributed this to what she described as "a glitch in the computer system" that prevented the resident's enrollment from being processed.
The situation escalated on December 14, 2023, when the facility's Nurse Practitioner ordered a psychiatric evaluation to assess the resident for auditory hallucinations. Records show the resident was enrolled for psychiatric services that same day—but the evaluation was never completed.
Over the following months, documentation shows the resident's symptoms persisted and worsened:
- March 2024: A physician noted the resident had "some issues with staff overnight relative to staff talking through the intercom" and that it was "unclear whether the Resident was having delusions."
- April 2024: Nursing staff documented "increased paranoia" with the resident describing "staff messing with him/her over the intercom, specifically overnight" and "saying his/her name over and over again."
- May 2024: A Nurse Practitioner note indicated the resident "had been complaining about people playing tricks on him/her over the intercom at night" and was "quite paranoid about this and could not sleep." The NP documented suspicion of auditory hallucinations and started the resident on Seroquel, an antipsychotic medication.
- June 2024: The resident reported "voices over the intercom at night and was fearful people were trying to poison him/her" and "thought Nurses were trying to kill him/her with medications."
Evaluation Finally Completed After Six Months
The psychiatric evaluation ordered in December 2023 was not completed until June 11, 2024—approximately six months after it was ordered. The evaluation confirmed the resident was experiencing auditory hallucinations and paranoia.
When asked about the delay, the Nurse Practitioner told surveyors that when she made a referral, "she expected that the other professionals would follow through on providing the service." She also stated that "even if the Psych Provider had evaluated the Resident, she did not think they would have done anything differently than what she did for the Resident."
The Director of Nursing explained that the psychotherapist who evaluated the resident in November 2023 left the facility at the end of 2023, and "it took a few months for the contracted Behavioral Health Agency to find a replacement." She said facility staff provided "additional support" during this period, suggesting the social worker was involved and the Nurse Practitioner "oversaw the Resident and initiated Seroquel for the Resident's behaviors."
However, the facility could not provide surveyors with evidence of any communications made to obtain psychotherapy services after the November 2023 evaluation, nor documentation that staff followed up with the Behavioral Health Agency about the missing services.
The Behavioral Health Manager acknowledged during a post-survey interview that "there was nothing in the Resident's file indicating that the Psychotherapy Services and the Psychiatric Evaluation were not to be completed for the Resident." She characterized the errors as "atypical" and expressed hope "this would not happen to other residents."
Understanding the Clinical Implications
The delay in psychiatric evaluation represents a significant gap in care for a vulnerable resident. Auditory hallucinations and paranoid thinking are distressing symptoms that can severely impact quality of life, causing fear, sleep disruption, and mistrust of caregivers. Early psychiatric intervention allows for proper differential diagnosis—distinguishing between conditions like dementia-related psychosis, medication side effects, or primary psychiatric disorders—and enables more targeted treatment.
While the facility did eventually initiate antipsychotic medication, doing so without a completed psychiatric evaluation meant treatment decisions were made without the benefit of specialized assessment. The resident's escalating symptoms over the six-month period—progressing from hearing their name called to believing staff were trying to poison and kill them—illustrate how untreated psychiatric symptoms can intensify over time.
For catheter care, standard nursing protocols require verification that equipment matches physician orders before insertion. The failure to maintain adequate supplies and the lack of documentation when substitute equipment was used created a situation where a cognitively impaired resident—unable to advocate for themselves—received care that deviated from their treatment plan for nearly two weeks.
Additional Issues Identified
The inspection cited deficiencies under two federal regulatory tags:
F690 - Urinary Catheter Care: The facility failed to ensure appropriate catheter care, specifically by not replacing a blocked catheter with the correct balloon size as ordered. This deficiency was categorized as causing minimal harm or potential for actual harm, affecting few residents.
F740 - Behavioral Health Services: The facility failed to provide behavioral health care and services to maintain the highest practicable mental and psychosocial well-being, including failure to obtain ordered psychotherapy counseling and delayed psychiatric evaluation. This deficiency was also categorized as causing minimal harm or potential for actual harm, affecting few residents.
Both deficiencies reflect systemic issues in care coordination—between nursing staff and central supply for catheter equipment, and between the facility and contracted behavioral health providers for psychiatric services. The facility's policy on Behavioral Health Services states that residents "will receive behavioral health services as needed to attain or maintain the highest practicable mental and psychosocial well-being," a standard that was not met in the documented case.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Holden Rehabilitation & Nursing Center from 2025-02-13 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.