Kit Carson Nursing: Catheter Monitoring Failures - CA
Resident 1 arrived at the local emergency department on June 23 at 1:17 PM, complaining of 10/10 pain at their catheter site. The catheter had been replaced just two days earlier at the hospital on June 21. When nurses tried to flush the tube with sterile water to clear blockages, they encountered resistance and no urine output appeared.
The resident requested immediate transport to the emergency department.
Hospital tests revealed a catheter-associated urinary tract infection. Given the test results and the resident's history of previous infections, doctors prescribed empiric antibiotics to treat the suspected infection.
The emergency visit could have been prevented. Kit Carson Nursing & Rehabilitation Center's own policy required staff to monitor residents with catheter changes every shift for 72 hours after the procedure. Records show nursing staff repeatedly skipped this monitoring.
Documentation gaps appeared throughout the required monitoring period. No monitoring was recorded during the day shift on August 6. No monitoring was noted during the night shift on August 6. No monitoring appeared for the morning shift on August 7. The pattern continued through the night shift on August 7.
During an interview on August 20, the Director of Nursing confirmed that monitoring "were not consistently completed for the 72-hour duration as required." She acknowledged the monitoring failures occurred across multiple dates and shifts.
The nursing director explained the purpose behind the 72-hour monitoring requirement. "Monitoring the suprapubic catheter for 72 hours after it was changed was to ensure if there was a change in Resident 1's condition, nursing could coordinate with the physician in case there were additional changes or orders that needed to be carried out."
She identified specific risks to the resident. "There was a risk for Resident 1 to acquire an infection and was at risk for pain."
Both risks materialized. The resident developed a urinary tract infection and experienced maximum pain levels that required emergency medical intervention.
The facility's written policy emphasized prompt communication with physicians. "All symptoms and unusual signs will be communicated to the physician promptly," the Change of Condition policy stated. It required licensed nurses to "continue assessment and documentation every shift for seventy-two (72) hours."
Staff violations extended beyond monitoring failures. Resident 1 had no care plan addressing suprapubic catheter changes or the June 23 urinary tract infection.
The nursing director admitted both oversights during the August 20 interview. She confirmed "Resident 1's care plans had not been updated to include Resident 1's UTI on 6/23/25 and it should have been." She acknowledged "there was not a care plan in place for catheter changes and there should have been."
Care plans serve as essential guides for nursing staff. The director explained their importance: "to ensure licensed nurses had a guide on how to take care of the Resident 1's suprapubic catheter."
The facility's own policy defined care plans as "the summation of the resident concerns, goals, approaches and interventions in order to meet the goals and help minimize if not totally eradicate residents' problems." The policy required evidence that care plans had been reviewed and updated with new interventions.
Neither requirement was met for Resident 1.
Suprapubic catheters require careful monitoring because they bypass the body's natural defenses against infection. The tubes, surgically placed through the abdomen directly into the bladder, provide an alternative to traditional urethral catheters for patients who need long-term bladder drainage.
When properly monitored, catheter changes typically proceed without complications. The 72-hour monitoring period allows nurses to detect early signs of infection, blockage, or other problems before they become serious enough to require emergency intervention.
Resident 1's experience illustrates what happens when monitoring protocols fail. A routine catheter change became a medical emergency requiring ambulance transport and hospital treatment.
The resident experienced maximum pain levels at the catheter site. Hospital tests confirmed the infection that proper monitoring might have detected earlier. The emergency department visit and antibiotic treatment became necessary consequences of missed nursing assessments.
Federal inspectors documented the monitoring failures during their August 20 investigation. They found a pattern of missed assessments across multiple shifts and dates, not isolated incidents.
The nursing director's acknowledgment that monitoring "were not consistently completed" confirmed systematic failures rather than occasional oversights.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kit Carson Nursing & Rehabilitation Center from 2025-08-20 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: August 2, 2026 · Our methodology
KIT CARSON NURSING & REHABILITATION CENTER in JACKSON, CA was cited for violations during a health inspection on August 20, 2025.
Resident 1 arrived at the local emergency department on June 23 at 1:17 PM, complaining of 10/10 pain at their catheter site.
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.