The incident occurred at Montcare at Bethesda on November 1, 2024, when Licensed Practical Nurse #3 and Registered Nurse #4 performed a straight catheterization on Resident #4 to collect a urine sample. Both nurses were suspended pending investigation.
Resident #4, who scored 15 on a mental status exam indicating intact cognitive function, told federal inspectors the nurses asked if he could walk to the bathroom for a urine sample. When the resident said no, the nurses proceeded to insert a catheter without obtaining consent or explaining the procedure.
The resident contacted the local police department the next day, feeling violated by what had happened.
A physician had ordered blood work and a urinalysis on October 31 to rule out infection, but there was no evidence that straight catheterization had been ordered. The facility's own policy, revised as recently as February 2025, requires both a physician's order and patient consent for catheterization procedures.
"Urinary catheters shall be inserted by licensed nurses under the orders of the attending physician," the policy states. "For straight or intermittent catheterizations, obtain a physician's order for frequency of catheterization."
Licensed Practical Nurse #2 confirmed during interviews that nurses were expected to inform and explain procedures before obtaining urine specimens from alert residents. The nurse added that both resident consent and a physician's order would be necessary for straight catheterization.
The Director of Nursing acknowledged to inspectors that no catheterization order had been obtained because the procedure was completed based on the nurse's judgment. The facility reported the incident internally on November 3, and the resident filed a formal complaint the following day.
A straight catheterization involves inserting a thin, hollow tube through the urethra into the bladder to drain urine, then removing it after the bladder empties. The procedure requires specific medical training and carries risks of infection and trauma if performed improperly.
The resident called the Director of Nursing on November 2 to report that two nurses had collected a urine sample against his will around 3 AM the previous day. Progress notes from that conversation documented the resident's account of the unauthorized procedure.
Federal inspectors determined the facility failed to provide appropriate treatment according to physician orders and resident preferences. The violation was classified as causing minimal harm or potential for actual harm.
The president of Clinical Services was notified of the violation and acknowledged the concern during the October inspection. The facility suspended both nurses involved while conducting its internal investigation.
Resident #4's case illustrates broader concerns about consent and proper procedures in nursing home care. The resident's intact mental capacity made the lack of explanation and consent particularly egregious, as facility staff knew they were dealing with someone fully capable of understanding and agreeing to medical procedures.
The timing of the incident, occurring at 3 AM when oversight is typically minimal, raises questions about night-shift supervision and adherence to medical protocols. The resident's decision to contact police rather than just facility management suggests the severity of feeling violated by the unauthorized medical procedure.
The facility's own policies clearly outlined the requirements that were ignored. The February 2025 revision of the catheterization policy indicates recent attention to these procedures, making the November violation more concerning given the updated guidelines.
Both the facility incident report and the resident's formal complaint were filed within days of each other, creating a paper trail that federal inspectors used to document the violation. The suspension of both nurses pending investigation shows the facility recognized the seriousness of the breach.
The case highlights the vulnerability of nursing home residents even when they retain full cognitive capacity. Despite being mentally intact and able to communicate preferences, Resident #4 was subjected to an invasive medical procedure without consent or proper authorization.
The resident's call to police demonstrates the lasting impact of the violation, extending beyond the immediate physical procedure to feelings of violation and loss of autonomy that prompted involvement of law enforcement.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Montcare At Bethesda from 2025-10-10 including all violations, facility responses, and corrective action plans.