PORT CHARLOTTE, FL - A nursing home resident experienced life-threatening complications requiring emergency hospitalization after staff failed to properly monitor his urinary catheter for over 15 hours, leading to severe bleeding and blood clots, according to a federal inspection report.
Critical Catheter Care Breakdown
Charlotte Bay Rehab and Care Center faced immediate jeopardy violations in March 2025 following an incident that began when nursing staff changed a resident's urinary catheter but failed to verify it was functioning properly. The 81-year-old male resident, who had been admitted with an enlarged prostate condition, went without documented urine output for more than 15 hours while staff failed to recognize the emergency.
On January 28, 2025, at approximately 5:30 a.m., Licensed Practical Nurse Staff B changed the resident's catheter per physician orders. However, inspection records reveal she documented getting only "a small amount of urine return" during insertion and left her shift at 7:00 a.m. with no urine visible in the drainage bag. Critically, she failed to document this concerning finding or alert other staff to monitor the situation closely.
The resident remained without urine output throughout the day, with multiple nursing staff failing to recognize the severity of the situation. When staff finally attempted to irrigate the catheter around 4:00 p.m., they discovered blood clots. Upon catheter removal, "copious amounts of blood came out," according to the Advanced Practice Registered Nurse who provided telephone orders.
Medical Significance of Urinary Retention
Urinary retention, particularly in patients with enlarged prostate conditions, represents a serious medical emergency that requires immediate intervention. When urine cannot drain properly, it can lead to dangerous complications including urinary tract infections, kidney damage, sepsis, and severe bleeding when blood clots form in the bladder.
For patients with indwelling catheters, proper drainage is essential to prevent these life-threatening complications. Medical standards require nursing staff to monitor urine output regularly and immediately investigate any absence of drainage. Extended periods without urine output, particularly over eight hours, warrant immediate physician notification and potential emergency intervention.
The formation of blood clots in the urinary tract, as occurred in this case, indicates significant trauma and requires urgent medical attention. When combined with the resident's prescribed anticoagulant medications (blood thinners like aspirin and Plavix), the risk of severe bleeding complications increases dramatically.
Staff Training and Competency Gaps
The inspection revealed systemic failures in staff training and competency verification that contributed to this dangerous situation. Multiple Licensed Practical Nurses involved in the resident's care lacked proper training in urinary catheter management, despite the facility's acceptance of residents requiring such specialized care.
LPN Staff B, hired in April 2024, had not received orientation on indwelling urinary catheter care and was never validated as competent to safely insert catheters. Similarly, other nursing staff involved in the incident - including Staff A, Staff C, and Staff D - had orientation records that failed to include catheter care competencies.
The facility's Staff Educator acknowledged that "the facility has not been doing urinary catheter care competencies" and failed to ensure nurses were knowledgeable about catheter insertion and monitoring procedures. When pressed to implement competency evaluations during the inspection, the educator admitted to checking off skill validation boxes without actually observing staff perform catheter insertions.
This represents a fundamental failure in healthcare administration, as nursing homes that accept residents with complex urinary conditions must ensure their staff possess the necessary skills to provide safe care.
Communication and Documentation Failures
The incident highlighted serious gaps in communication between nursing shifts and inadequate documentation of the resident's deteriorating condition. The Advanced Practice Registered Nurse reported she was never informed the resident had been without urine output for over eight hours - information that would have prompted immediate hospital transfer.
Staff failed to follow proper chain of command protocols, with one nurse not transcribing critical physician orders until five hours after receiving them. The transcribed order also omitted important monitoring requirements for bleeding and blood clots, further compromising the resident's safety.
Documentation gaps extended throughout the incident, with no recorded vital signs during the acute bleeding episode, no progress notes detailing the resident's condition changes, and inadequate shift-to-shift communication about the severity of the situation.
Emergency Response and Hospitalization
By 10:00 p.m. on January 28, the resident's condition had deteriorated to the point requiring emergency medical services transport. Staff documented the resident was "lethargic" and continued experiencing bleeding and blood clots. The family was notified, and Emergency Medical Services transported the resident to the hospital for evaluation.
The resident's spouse later reported that her husband required life support due to complications from urinary tract infection and pneumonia that developed during his nursing home stay. This outcome underscores the serious medical consequences that can result from inadequate monitoring of seemingly routine medical devices like urinary catheters.
Immediate Jeopardy Determination and Response
Federal inspectors determined the facility's failures created immediate jeopardy to resident health and safety - the most serious level of violation in nursing home regulations. The determination noted that inadequate staff competencies created "a likelihood of serious harm, rehospitalization and death" for residents requiring catheter care.
Following notification of the immediate jeopardy finding, Charlotte Bay Rehab and Care Center implemented comprehensive corrective measures. The facility educated 48 of 50 licensed nurses on change-in-condition assessments, implemented new competency requirements for catheter care, and established enhanced monitoring protocols for residents with urinary catheters.
Additional corrective actions included mandatory vital sign competencies for all staff, daily audits of catheter output documentation, and enhanced shift-to-shift communication protocols. The facility also revised orientation procedures to ensure all newly hired licensed nurses complete catheter care competencies before providing resident care.
Additional Issues Identified
Beyond the critical catheter care failures, the inspection identified broader systemic issues affecting facility administration and resource management. The facility assessment tool, designed to ensure adequate staffing and capabilities for resident care, had not been properly utilized to identify training needs for complex medical conditions.
The quality assurance and performance improvement program failed to proactively identify risks associated with inadequate staff competencies. An ad hoc quality meeting was held only after the serious incident occurred, rather than preventing such situations through proper oversight and staff development.
Record keeping and incident investigation procedures also required improvement, with the facility's initial investigation concluding that neglect could not be verified, despite clear evidence of inadequate monitoring and care coordination.
The immediate jeopardy determination was removed on March 22, 2025, after inspectors verified implementation of acceptable corrective measures and confirmed improved care practices through resident record reviews, staff interviews, and direct observation of nursing procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare of Port Charlotte from 2025-03-22 including all violations, facility responses, and corrective action plans.
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