HANCOCK, MI - A Michigan nursing home faces citation after staff inserted a urinary catheter into a dementia patient without obtaining required physician orders or notifying the resident's family, according to a state inspection completed May 29.
Unauthorized Medical Procedure Raises Safety Concerns
During a routine health inspection at Portagepointe in Hancock, state surveyors discovered that nursing staff had inserted a Foley catheter into a resident with severe cognitive impairment without following proper medical protocols. The facility failed to obtain physician orders before the procedure and did not notify the patient's responsible family member.
The resident, identified in the report as having a history of urinary tract infections, Alzheimer's disease, dementia, and anxiety disorder, was admitted to the facility earlier this year. Medical records indicated the patient's cognitive skills were severely impaired and the individual rarely or never made independent decisions.
According to the inspection report, a registered nurse made an independent decision to insert the catheter after observing the resident "seeping urine." During interviews with state inspectors, the nurse acknowledged not calling the attending physician for orders and failing to contact the family member designated as the responsible party.
Family Member Unaware of Medical Intervention
The violation came to light when inspectors contacted the resident's family member, who expressed surprise and concern about the catheter placement. "I want to call the facility right away to find out why [the resident] has a catheter," the family member told inspectors during a phone interview.
The lack of family notification represents a significant breach of protocol, particularly for residents with cognitive impairments who cannot provide informed consent for medical procedures. Federal regulations require nursing homes to involve families or designated representatives in care decisions when residents lack decision-making capacity.
Medical Risks of Inappropriate Catheter Use
Urinary catheters carry substantial infection risks and should only be used when medically necessary. The Centers for Disease Control and Prevention identifies catheter-associated urinary tract infections as one of the most common healthcare-associated infections, particularly dangerous for elderly residents who may have compromised immune systems.
Each day a catheter remains in place increases infection risk by approximately 3-7%. For residents with a history of urinary tract infections, like the patient in this case, unnecessary catheter use poses even greater dangers. UTIs in elderly patients can lead to serious complications including kidney infections, bloodstream infections, and increased confusion or delirium in those with dementia.
Medical best practices emphasize that catheters should be avoided for incontinence management except in specific circumstances such as acute urinary retention, accurate measurement of urinary output in critically ill patients, or to assist healing of open sacral or perineal wounds. Simple urinary leakage or incontinence does not constitute an appropriate indication for catheter insertion.
Facility Leadership Acknowledges Protocol Failures
The facility's Director of Nursing confirmed to inspectors that proper procedures were not followed. The DON acknowledged the physician was not called to obtain doctor's orders to insert a catheter and conceded there was no diagnosis that would necessitate the use of a urinary catheter, according to the inspection report.
This admission highlights a fundamental breakdown in the facility's medical oversight processes. Nursing homes are required to have systems ensuring that all medical interventions receive appropriate physician authorization and that families are informed of significant changes in their loved one's care.
Industry Standards Violated
The facility's own policies, last updated in March 2024, specifically addressed proper catheter protocols. The policy document emphasized inserting catheters "only for appropriate indications" and explicitly stated to "avoid use of urinary catheters in elders for management of incontinence." The policy also required staff to "confirm provider's (physician) order" and "confirm appropriate diagnosis for insertion of foley catheter."
These internal guidelines aligned with established medical standards that recognize the heightened vulnerability of elderly patients to catheter-related complications. Professional nursing standards require healthcare providers to explore less invasive alternatives for incontinence management before considering catheter insertion.
Alternative Incontinence Management Options
Proper incontinence care for nursing home residents typically involves a comprehensive assessment to identify underlying causes and implement appropriate interventions. These may include scheduled toileting programs, behavioral modifications, treatment of underlying medical conditions, use of appropriate absorbent products, and environmental modifications to improve bathroom access.
For residents with dementia, incontinence management often requires patience, consistent caregiving approaches, and sometimes medication adjustments under physician supervision. The goal should always be maintaining dignity while using the least restrictive intervention necessary.
Additional Issues Identified
The inspection focused specifically on catheter care protocols, with surveyors reviewing procedures for two residents. The violation affected one of the two residents examined, indicating the need for facility-wide review of medical procedure authorization processes.
The citation carries a designation of "minimal harm or potential for actual harm" affecting "few" residents, though the potential for serious complications from inappropriate catheter use remains significant for the affected individual.
State regulations require nursing homes to submit correction plans addressing identified deficiencies to maintain their certification for Medicare and Medicaid participation. Facilities must demonstrate they have implemented systems to prevent similar violations in the future.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Portagepointe from 2025-05-29 including all violations, facility responses, and corrective action plans.
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