The resident required a coude foley catheter — flexible tubing with a bent tip designed to navigate around obstructions like an enlarged prostate. His physician ordered the 24 French catheter changed monthly by a registered nurse only, due to his obstructive uropathy that blocks normal urine flow.
Employee 1, a licensed practical nurse, documented changing the resident's catheter on July 30, 2025. The physician's order from May 31 through August 29 explicitly stated "This may only be changed by the registered nurse."
The distinction matters for this type of catheter. A coude catheter's curved tip requires specialized insertion technique to pass beyond prostate obstructions. The facility's own physician orders recognized this complexity by restricting the procedure to registered nurses.
Records show the resident's catheter was changed again just nine days later. Employee 6, a registered nurse, replaced the catheter on August 8, documenting the change as "effective for blockage/obstruction." This suggests the July 30 catheter change by the LPN may have failed or caused complications requiring immediate replacement.
The pattern continued with irregular timing. The Director of Nursing changed the catheter again on August 29 for what documentation called a "monthly change" — just 21 days after the August 8 replacement.
Inspectors found no evidence in the resident's clinical record of complications that would justify changing the catheter before the standard 30-day interval. The physician had ordered monthly changes "and as needed for blockage or obstruction," but records contained no documentation of such complications between August 8 and August 29.
The facility's treatment administration records revealed additional confusion. Employee 2, another licensed practical nurse, documented on April 30, 2025, that "a registered nurse changed Resident 1's coude catheter on August 29, 2025" — a date four months in the future from when the note was written.
The resident's catheter specifications changed during his stay. Initially ordered as a 24 French coude foley with a 10 cc balloon, the physician modified the order on August 29 to require a 30 cc balloon while maintaining the monthly change schedule and registered nurse requirement.
French sizing indicates catheter diameter, with each French unit equaling approximately 0.33 millimeters. A 24 French catheter measures roughly 8 millimeters across. The balloon size — 10 cc versus 30 cc — determines how much sterile water inflates the retention balloon that keeps the catheter in place inside the bladder.
These technical specifications matter for residents with obstructive uropathy. The condition, commonly caused by enlarged prostates in older men, requires careful catheter management to prevent further complications. Improper insertion or sizing can worsen blockages or cause tissue damage.
The Nursing Home Administrator confirmed the findings during a September 16 interview with inspectors. The facility acknowledged that Employee 1, the licensed practical nurse, had performed a procedure reserved for registered nurses according to the physician's explicit orders.
Federal regulations require nursing homes to provide treatments and services as ordered by physicians. The distinction between licensed practical nurses and registered nurses exists because RNs complete additional education and clinical training for complex procedures.
Pennsylvania nursing regulations specify different scopes of practice for LPNs and RNs. While both can perform basic catheter care, specialized procedures like coude catheter insertion typically fall under RN responsibilities, especially when physician orders specify this requirement.
The violation affected one resident but highlighted broader questions about staff training and supervision. When a physician restricts a procedure to registered nurses, the facility must ensure compliance through scheduling, staff assignments, and oversight.
Rolling Hills failed to implement systems ensuring the resident received catheter changes from appropriately licensed staff. The LPN's July 30 catheter change violated the physician's order, potentially contributing to the need for replacement just nine days later.
The resident continues requiring monthly catheter changes for his obstructive uropathy. Whether the facility has corrected its procedures to ensure only registered nurses perform future changes remains unclear from the inspection findings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rolling Hills Healthcare and Rehabilitation Center from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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