Putnam County Care Center: Catheter Care Failures - MO
The resident went two days without producing any urine.
An August 28 complaint inspection at Putnam County Care Center documented what followed that decision. The resident's perineal skin and the tissue around the catheter insertion site peeled and became red and swollen, with purulent drainage. By early morning on a day inspectors documented as 5:38 a.m., the resident was so tender at the perineal skin and meatus that any touch caused extreme distress. Inspectors wrote that the resident became "very anxious and upset, almost violent when touched in any manner."
Nobody had called the physician. Nobody had called the family.
RN A, interviewed on August 13, said the resident had been pulling on the catheter tubing after returning from the hospital, causing pain and trauma to the skin around the insertion site. She removed it because the resident was in discomfort and because she saw no diagnosis in the chart that explained why the catheter had been placed. After removing it, she notified the physician by secure text app. She did not call the discharging hospital. She did not call the physician before acting.
Two days passed with the resident producing no urine at all. Another nurse then performed a straight catheterization to check for residual urine. That procedure also required a physician's order. There was none.
LPN B, also interviewed on August 13, described the same sequence and acknowledged the gaps. A nurse should have had an order to place the catheter, an order to remove it, and an order for any straight catheterization that followed. After removal, staff should have been monitoring for urine output, checking for bladder distension, and watching for signs of pain or difficulty voiding. If straight catheterization became necessary, a physician's order was required first, and the physician needed to be told about the resident's condition.
None of that happened.
The Director of Nursing, interviewed that same afternoon, said she had not been sure why the resident came back with a catheter. She confirmed no staff had called the discharging hospital to find out. No one had notified the physician that the catheter existed when the resident was readmitted, and there was no physician's order for it anywhere in the medical record. She said staff should have obtained an order before removing it and should have contacted the physician before proceeding with straight catheterization.
The facility's own physician, also interviewed on August 13, said the facility communicated with him through a secure text app, fax, and phone calls. He said staff should have had his orders for catheter placement, removal, and any straight catheterization. He said he should have been notified when the resident was unable to void and when the resident was in pain.
The administrator, interviewed at 2:40 that afternoon, said staff should have figured out why the resident had the catheter when they came back from the hospital and should have contacted the physician before discontinuing it.
Everyone interviewed said what should have happened. The record showed what did.
The resident, whose name was not included in the inspection report, spent at least two days unable to urinate while the perineal tissue around the catheter site deteriorated. When inspectors documented the resident's condition, the skin had already peeled, the area was swollen and red, and there was purulent drainage. The resident had become so sensitive to touch that basic care caused near-violent distress.
The inspection was classified as a complaint survey. The harm level was listed as minimal harm or potential for actual harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Putnam County Care Center from 2025-08-28 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 4, 2026 · Our methodology
PUTNAM COUNTY CARE CENTER in UNIONVILLE, MO was cited for violations during a health inspection on August 28, 2025.
The resident went two days without producing any urine.
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.