The January 28 incident triggered immediate jeopardy violations — the most serious finding federal inspectors can issue — when they determined the facility's nursing staff lacked basic competencies to safely care for residents with indwelling catheters.
Licensed Practical Nurse Staff B changed Resident #1's urinary catheter at approximately 5:30 a.m. on January 28. She did not ensure free flow of urine to verify the catheter tip was properly positioned in the bladder.
For the next nine and a half hours, Unit Manager LPN Staff D failed to monitor Resident #1 to ensure the catheter was functioning and draining urine. The monitoring gap stretched from 7:00 a.m. to 2:00 p.m.
At approximately 5:00 p.m., LPN Staff A received a physician's order to monitor Resident #1 and send him to the hospital. The catheter had been removed and the resident was experiencing significant bleeding and passing blood clots from his penis.
She did not monitor the resident.
Staff A also failed to transcribe the physician's order until 10:00 p.m. — five hours after receiving it.
By then, Resident #1 was unresponsive and bleeding through his penis. Emergency medical services transferred him to an acute care hospital, where he was intubated in the emergency room and admitted to the intensive care unit.
Federal inspectors determined the facility's failure to ensure licensed nurses had competencies to provide safe catheter care placed residents at likelihood of significant harm, injury or death from complications including trauma from improper insertion, urinary tract infections, and blood infections.
The administrator was notified of the immediate jeopardy determination on March 20 at 4:45 p.m.
The facility launched comprehensive corrective measures beginning March 18. Staff education on abuse and neglect focused on the failure to protect resident rights by failing to monitor urinary output and residents when catheters were discontinued.
By March 21, 141 of 171 staff members had received this education. All remaining staff would receive training before returning to work.
The facility completed a facility-wide audit of 155 residents on March 18 to ensure physician orders for vital signs were in place and transcribed to medication administration records. Long-term care residents receive vital signs weekly while short-term rehab residents receive them daily.
All foley catheter orders were reviewed March 18. Urinary output was added to medication administration records the following day to ensure nursing documentation.
Certified nursing assistant education began March 18 to ensure changes in urinary output for catheter residents and any changes in resident condition were reported immediately to nurses.
By March 21, 77 of 82 CNAs were educated. Remaining CNAs would receive education before their next scheduled shifts.
Vital sign assessment competencies for temperature, pulse, respirations, and blood pressure were initiated March 21.
Licensed nurses received education March 18 on completing Change in Condition Assessments. The training covered identifying conditions requiring assessment including accidents resulting in injury, significant changes in physical or mental condition, deterioration in health status, life-threatening conditions, clinical complications including changes in urinary output, and circumstances requiring treatment alterations.
Nurses were educated to obtain new vital signs and document them electronically so Change in Condition Assessments contained the most recent relevant information. Providers must be notified of pertinent evaluation findings. Nurses must visualize catheters for urine amount, color and clarity during each shift.
The daily clinical meeting agenda was revised March 19 to include review of all residents with condition changes to ensure vital signs and timely transfers were completed, and review of all residents with urinary catheters to ensure monitoring and documentation of urine output.
Registered nurses conducted assessments March 19 of every current resident including vital signs and foley catheter observations for output and patency. Changes were reported to families and providers.
Audits began March 20 to ensure nursing staff properly documented vital signs. A seven-day audit for catheter residents ensured measuring and documenting urine output on each shift.
An unplanned Quality Assurance and Performance Improvement meeting was held March 20 with a root cause analysis of the incident. Attendees included the medical director, director of nursing, administrator, human resources, social services, activities, therapy director, minimum data set nurse, nurse, and CNA.
By March 21, 48 of 50 nurses were re-educated. Remaining nurses would receive education before their next shifts.
When inspectors returned March 22, they verified through record reviews of three randomly selected residents that the facility was monitoring vital signs for short and long-term residents.
Interviews with three certified nursing assistants and three nurses confirmed they had been re-educated on catheter care including measuring, reporting, and documenting amounts on medication administration records.
Record reviews of three randomly selected catheter residents showed the facility was monitoring and documenting vital signs every shift. Nursing staff were measuring and recording urine amounts for catheter residents.
Three random CNAs confirmed through interviews they were educated to report changes in urinary output for catheter residents and changes in resident condition immediately to nurses.
Record reviews of three random residents verified the facility was documenting vital signs on medication administration records twice daily.
A review of three random resident records was completed March 22 to ensure accurate assessment and interventions were in place to prevent neglect related to catheter care and residents experiencing condition changes.
The inspection narrative does not indicate Resident #1's current condition or whether he survived the intensive care hospitalization following the 17-hour monitoring failure that left him unresponsive and 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.
Additional Resources
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