Oakwood Village East: Catheter Removed Without Doctor Order - WI
The resident, identified in inspection records only as R1, had a foley catheter that came with explicit instructions: do not manipulate, do not flush, do not exchange it, and do not pull it out. If anything went wrong, urology was to be notified. Those orders were in the medical record. The nurse, RN D, told inspectors she had read them.
Around 6:00 AM, RN D noticed the catheter wasn't draining and found R1's bed wet with urine. She checked the balloon that holds a foley catheter in place inside the bladder and found only 3 milliliters of fluid where there should have been more. She decided the catheter wasn't positioned correctly. Then she pulled it out.
After removing it, she left a voicemail for R1's primary provider. She tried to reach urology. She did not speak to anyone.
R1 was sent to the hospital emergency room later that morning so a urologist could replace the catheter. The resident's daughter accompanied them.
The urology clinic's own nurse told inspectors the facility got it wrong. UCN E, the urology clinical nurse interviewed on October 6, said the catheter should have been left in place because the nurse on the floor had no way to confirm where it actually was. "The facility should have contacted a provider and should not have removed the catheter," UCN E said. The clinic also had an after-hours number for exactly these situations. It went unused.
When inspectors sat down with the Director of Nursing, identified as DON B, the exchange was telling. The surveyor asked whether withdrawing fluid from the catheter balloon counted as manipulating the catheter. DON B said she did not believe it did. The surveyor then asked whether RN D should have consulted a provider before removing the catheter. DON B's answer focused on timing: the removal happened before the urology clinic opened at 8:00 AM, and RN D had tried to make contact afterward.
That framing, that the sequence of events was the problem rather than the decision itself, sat uneasily against what the urology clinic said. The clinic had an after-hours line. Nobody called it.
CMS rated the deficiency as causing minimal harm or potential for actual harm, and noted it affected few residents. The inspection was conducted as a complaint survey and completed October 22, 2025.
What the records don't resolve is what the early morning hours looked like for R1, lying in a wet bed while a nurse made a unilateral call that her own facility's orders had taken off the table. The catheter was gone before anyone with the authority to authorize its removal had been reached. The trip to the emergency room came next.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakwood Village East Health and Rehab Center from 2025-10-22 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: June 24, 2026 · Our methodology
OAKWOOD VILLAGE EAST HEALTH AND REHAB CENTER in MADISON, WI was cited for violations during a health inspection on October 22, 2025.
If anything went wrong, urology was to be notified.
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.