Federal inspectors found that Pelican Health Randolph LLC failed to follow medical orders for Resident #5, who required a catheter anchor to prevent the tubing from pulling during transfers and repositioning. The facility's medical director had specifically ordered the leg anchor as "best practice" to protect the resident's urethra.
The resident's nurse aide emptied urine collection bags every two hours and before transfers to reduce tension on the catheter tubing. But NA #3 told inspectors he had never noticed a securement device and simply tried to ensure the tubing wasn't pulling on the resident's urinary opening.
"I just made sure the urinary catheter tubing was not pulling on Resident #5's urinary opening," the aide said during the September inspection.
The wound nurse assigned to the resident's care on September 10 said she was only there for wound treatment. She told inspectors the resident's assigned nurse should have obtained the securement device from Central Supply and applied it.
Nobody did.
The facility's Director of Nursing, who started the position on September 10 after beginning work at Pelican Health in October 2024, acknowledged the failure. She told inspectors that nurses were expected to follow medical orders and care plans, and since Resident #5 had both an order and care plan for a catheter anchor, "the nurse should have placed the anchor or delegated to a nurse aide to place the anchor."
The medical director explained the serious risks the resident faced without proper catheter securement. A full urinary bag would add tension to the catheter tubing, increasing "the potential for trauma and the potential for stagnant urine to backflow into the bladder."
Resident #5 was being followed by urology specialists for chronic urinary tract infections and neurogenic bladder, a condition where nerve damage prevents normal bladder control. His nurse practitioner, who had worked with him since January 2025, said he hadn't experienced catheter dislodgement during her time treating him.
But the medical director's concerns about injury remained valid. He had written the catheter leg anchor order specifically to prevent urethral damage and catheter displacement when staff repositioned the resident during routine care.
The inspection revealed a breakdown in basic nursing protocols. While the nurse aide demonstrated awareness of catheter care by emptying bags regularly and timing empties before transfers, the facility failed to implement the physician-ordered safety measure designed to protect the resident during these same activities.
The wound nurse's limited assignment to the resident highlighted another gap in care coordination. Despite being present for wound treatment, she did not ensure the catheter securement was in place, referring inspectors to the assigned nurse who should have handled the task.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. But for Resident #5, the consequences of a catheter-related injury could have been severe, particularly given his underlying urological conditions and history of chronic infections.
The case illustrates how seemingly minor oversights in nursing home care can expose vulnerable residents to preventable harm. The medical director's order for a catheter anchor represented standard medical practice, yet staff failed to implement this basic safety measure over multiple shifts and care interactions.
The resident's complex medical needs - chronic UTIs, neurogenic bladder, and ongoing urology follow-up - made proper catheter management even more critical. Without the ordered securement device, every transfer and repositioning carried unnecessary risks of trauma, infection, and catheter failure.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health Randolph LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.