Putnam County Care Center: Catheter Removal Without Orders - MO
The incident happened July 1, when the resident returned to Putnam County Care Center from a hospital stay. The resident arrived with a catheter. No physician's order for it appeared anywhere in the medical record. The resident was pulling on the catheter and causing themselves pain.
RN A removed it. He or she did not call the hospital. Did not call the physician first. Sent a text through a secure messaging app after the catheter was already out.
For two days, the resident produced no urine. When a second nurse finally intervened, she performed a straight catheterization to drain residual urine, also without first obtaining a physician's order.
By the time inspectors examined the resident, the perineal skin and the area around the catheter site were peeled, irritated, red and swollen, with purulent drainage.
The Director of Nursing told inspectors on August 13 that she had not known why the resident came back with a catheter, and that no staff member had called the hospital to find out. "Staff should obtain an order for the urinary catheter and obtain a physician's order prior to removing the urinary catheter," she said.
The resident's physician said the facility communicated with him by text, fax and phone. He said staff needed orders before placing, removing or straight catheterizing, and should have notified him when the resident could not void and was in pain.
The administrator said staff should have determined why the catheter was there before touching it.
Nobody had.
The inspection, conducted August 28, classified the violation as causing minimal harm or potential for actual harm, with few residents affected. The resident whose catheter was removed without orders, who spent two days unable to urinate, whose skin around the site was swollen and draining, was not further identified in the report.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PUTNAM COUNTY CARE CENTER in UNIONVILLE, MO was cited for violations during a health inspection on August 28, 2025.
The incident happened July 1, when the resident returned to Putnam County Care Center from a hospital stay.
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.