Willows of Greensburg: Catheter Balloon Inflated in Penis - IN
The resident at Willows of Greensburg required emergency transport to the hospital on August 7, where a CT scan revealed the catheter balloon had been inflated inside his penile urethra instead of his bladder.
Resident C, who has severe cognitive impairment from Alzheimer's disease, had been experiencing increased fatigue that morning. At 8:50 a.m., Registered Nurse 2 documented contacting the facility's nurse practitioner, who ordered a new anchored urinary catheter and saline bolus treatment.
At 2:30 p.m., Registered Nurse 3 inserted a 16 French indwelling catheter with a 15-milliliter balloon. No urine flowed from the catheter after insertion.
The nurse proceeded anyway.
Nearly six hours later, at 8:29 p.m., a qualified medical assistant from another unit reported seeing blood in the catheter bag. Registered Nurse 3 documented finding "bright red blood" in both the catheter tubing and collection bag. Emergency Medical Services arrived and transported the resident to the hospital.
The facility's clinical record contained no documentation that staff had reassessed the catheter placement after the initial lack of urine return. Hospital imaging confirmed what the blood had indicated: the catheter balloon was inflated within the penile urethra, not the bladder where it belonged.
During the August 14 inspection, Registered Nurse 3 told investigators that after inserting a urinary catheter, "the nurse would need to make sure there was urine return in the tubing." If no urine appeared, she said, "the urinary catheter would need to be monitored to ensure urine return began."
But that monitoring never happened.
The facility's own policy, titled "Validation Checklist Catheterization (Male)" and dated 2023, explicitly states that catheters should be "inserted gently into the meatus or until urine began to flow from the bladder." The policy warns: "if resistance continued, do not force entry."
The resident's medical history complicated the situation. His diagnoses included end-stage renal disease, hypertension, atrial fibrillation, and Alzheimer's disease. The May 22 quarterly assessment had documented his severe cognitive impairment, meaning he likely could not communicate discomfort or pain from the misplaced catheter.
The nurse practitioner's original orders called for the catheter to be anchored and for aggressive fluid replacement: a 500-cubic-centimeter normal saline bolus over two hours, followed by 100 cubic centimeters every hour for 48 hours. These orders suggested the medical team was already concerned about the resident's kidney function and fluid status.
Instead, the botched catheter insertion created a new medical emergency.
Urethral trauma from incorrectly placed catheters can cause bleeding, infection, scarring, and long-term complications. When catheter balloons inflate in the urethra rather than the bladder, they can block urine flow entirely and cause severe pain. The bright red blood documented by staff indicated active bleeding from urethral tissue damage.
The incident occurred despite clear warning signs. Medical literature and nursing education emphasize that urine return is the primary indicator of proper catheter placement. When no urine flows after insertion, standard protocol requires immediate reassessment and potential repositioning or removal.
Federal inspectors noted that Resident C's case was connected to two separate complaints filed against the facility, numbered 2574159 and 2572941, though the inspection report does not detail those complaints' specific allegations.
The Director of Nursing provided the facility's catheterization policy to inspectors on August 14 at 3:53 p.m., seven days after the incident occurred. The policy's language about gentle insertion "until urine began to flow" directly contradicted what happened with Resident C, where staff proceeded despite no urine flow.
The inspection classified this as a violation causing "minimal harm or potential for actual harm" affecting "few" residents. But for Resident C, the consequences were immediate and serious: emergency hospitalization, invasive CT scanning, and potential urethral damage from the misplaced device.
The case illustrates how basic nursing procedures can become dangerous when staff ignore fundamental safety protocols. A catheter insertion that should have taken minutes instead resulted in hours of internal bleeding and emergency medical intervention for a vulnerable resident who could not advocate for himself.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willows of Greensburg from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WILLOWS OF GREENSBURG in GREENSBURG, IN was cited for violations during a health inspection on August 14, 2025.
Resident C, who has severe cognitive impairment from Alzheimer's disease, had been experiencing increased fatigue that morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.