Putnam County Care Center: Catheter Removed Without Doctor - MO
The sequence of decisions at Putnam County Care Center came to light during a complaint inspection completed August 28, 2025.
The resident had returned from a hospital stay on July 1, 2025, with a urinary catheter in place. RN A, the nurse who received the resident back at the facility, said the resident was pulling on the catheter and experiencing pain. There was no diagnosis in the resident's record that, in RN A's assessment, required a catheter. So RN A removed it.
Nobody called the discharging hospital. Nobody called the physician before the catheter came out. RN A notified the doctor afterward, through a secure text app.
The physician said he did not learn the resident had a catheter at all until after it had already been removed.
For two days, the resident had no urine output.
A second nurse then performed what is called a straight catheterization, a procedure to drain residual urine from the bladder. That nurse also did not notify the physician before acting.
The physician told inspectors the facility communicated with him through a secure text app, fax, and phone calls. He confirmed staff had not told him the resident was unable to void before the straight catheter was inserted.
The Director of Nursing said she was not sure why the resident had returned from the hospital with a catheter in the first place. She acknowledged that staff should have notified the physician before removing the original catheter, before inserting the straight catheter, and should have told the resident's family about the changes in condition and treatment. None of that happened.
The Administrator said the same thing: staff should have found out why the catheter was there before taking it out, and the physician and family should have been contacted before any of it.
What the inspection report describes is a gap between what everyone at the facility now agrees should have happened and what actually did. RN A made a clinical judgment call in the moment, pulled the catheter, and sent a text. Two days passed. The resident's bladder was not emptying. A second procedure followed, and the doctor still hadn't been reached in advance.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents.
The family was not notified of the change in the resident's condition or the change in treatment.
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 sequence of decisions at Putnam County Care Center came to light during a complaint inspection completed August 28, 2025.
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.