Federal inspectors found immediate jeopardy violations at Charlotte Bay Rehab and Care Center after the January incident involving a resident with an enlarged prostate who required a urinary catheter to drain urine from his bladder.
The resident's care unraveled over a week in late January when nursing assistants and licensed nurses documented wildly different urine output measurements, making it impossible to determine his actual condition. On January 22, a nursing assistant recorded 1,400 cc of urine output while the licensed nurse documented just 250 cc for the same period.
The discrepancies continued for days. On January 23, the assistant logged 700 cc while the nurse recorded 450 cc. By January 24, the assistant wrote "Response not required" while nurses documented 750 cc total.
No one documented any urine output for the night shift of January 27 or either shift on January 28.
On the morning of January 28, Licensed Practical Nurse Staff B changed the resident's urinary catheter per physician orders. The clinical record contains no documentation that she verified the catheter was properly inserted and draining urine. When she left work at 7:00 a.m., there was no urine in the drainage bag.
When Staff B returned that evening at 7:00 p.m., another nurse told her the resident had produced no urine since the previous evening. He only passed blood and clots when staff tried to irrigate the catheter.
An Advanced Practice Registered Nurse ordered the catheter removed at 5:00 p.m. due to blood and clots with no urine output. The order instructed staff to monitor the resident and send him to the emergency room if he didn't urinate within a couple hours and clots continued.
But Licensed Practical Nurse Staff A didn't transcribe the order until 10:02 p.m., five hours after receiving it and after the resident had already been transferred to the hospital.
During those critical hours, staff failed to monitor the resident's vital signs or assess the amount of bleeding. Staff B told investigators she took the resident's vital signs twice during her shift but never documented them. She said the resident was alert but lethargic when Emergency Medical Services arrived, but couldn't remember when he became lethargic.
Emergency Medical Services received the dispatch call at 9:51 p.m. on January 28. The EMS report documented finding the resident lying face up in bed, unresponsive but breathing. A facility nurse told EMS that the resident had his catheter removed earlier and had been having penile bleeding with blood clots.
The nurse told EMS she couldn't wake the patient up, though he was normally awake and verbal. He had been seen normal three hours earlier.
EMS documented the resident as unresponsive with fast breathing, hot and clammy skin, and bruising on his abdomen. The primary complaint was listed as "unresponsive" and "bleeding from penis with large blood clots." Symptom onset was recorded as 6:07 p.m. on January 28.
At the hospital emergency room, the resident arrived at 10:22 p.m. with a temperature of 100.2 degrees, unresponsive to painful stimuli. The hospital noted he came from the nursing home for blood clots after catheter removal.
A week later, on February 4, the resident's spouse called the facility to report her husband was on life support at the hospital due to a urinary tract infection and pneumonia she said he acquired during his stay due to improper care.
The facility launched an investigation but concluded they couldn't verify the neglect allegation. Their investigation noted that nursing staff education had been initiated regarding catheter care, but investigators failed to examine critical gaps in care.
The facility's investigation didn't address the lack of monitoring of urinary output, the nurse's failure to document proper catheter placement, or the absence of vital sign monitoring when the resident experienced acute bleeding and changed mental status.
Staff interviews revealed systemic failures in training and oversight. RN Staff F, the facility's educator for seven years, told inspectors that Licensed Practical Nurse Staff B had worked there since April 2024 but never received competency training on urinary catheter insertion and monitoring.
"The facility had not been doing urinary catheter care competencies, and did not ensure the nurses were knowledgeable to insert catheters and monitor residents with urinary catheters," Staff F said. "We will now."
She provided a skills checklist the facility began using on March 18, three days before the federal inspection. But Staff F admitted she had checked boxes indicating Staff B was competent without actually observing her insert a urinary catheter.
The Director of Nursing acknowledged she hadn't reviewed the resident's clinical record for accuracy until concerns were raised during the federal inspection. She admitted the facility's investigation focused on the spouse's complaints rather than examining the clinical care failures that led to the emergency transfer.
Registered Nurse Staff E explained the facility's policy required documenting intake and output on the Treatment Administration Record, with nurses getting output measurements from nursing assistants each shift. But the system broke down completely in this case, with no one reconciling the conflicting documentation or investigating why measurements differed so dramatically.
The facility accepts residents with various urinary conditions including neurogenic bladder, enlarged prostate, and urinary incontinence. Their assessment tool notes they provide intermittent and indwelling catheter services based on resident needs.
Federal inspectors found immediate jeopardy violations, meaning the facility's failures placed residents in immediate risk of serious harm or death. The violations were removed on March 22 after the facility implemented extensive corrective measures.
The corrective actions included retraining 42 of 50 nurses on catheter insertion with return demonstrations, educating 77 of 82 nursing assistants on reporting changes in urine output, and implementing daily audits of all residents with urinary catheters.
The facility also revised their clinical meeting format to review all residents with condition changes, ensuring vital signs are monitored and transfers completed timely. All 141 of 171 staff members received education on abuse and neglect, with emphasis on the failure to monitor this resident's condition.
But for one resident's family, the systematic training came too late. The man who entered the facility with an enlarged prostate requiring routine catheter care ended up unresponsive on life support, his condition deteriorating over days while staff documented conflicting information and failed to recognize the severity of his bleeding.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Charlotte Bay Rehab and Care Center from 2025-03-22 including all violations, facility responses, and corrective action plans.
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