Federal inspectors found that nursing staff missed catheter monitoring, flushing treatments, and routine care for Resident 104, who was admitted with quadriplegia, spinal stenosis, and had suffered a transient ischemic attack. The resident scored 15 out of 15 on cognitive assessments, indicating full mental awareness of their care.
The patient required both a urinary catheter and a suprapubic catheter due to an obstructive neurogenic bladder. Physician orders specified detailed care requirements: catheter output monitoring every day and night shift, daily flushing with 60ml of normal saline, and catheter care twice daily.
But treatment records showed gaps in care throughout October and November 2025.
Staff failed to monitor catheter output on October 21 and 24 during day shifts, and missed night shift monitoring on October 24 and 25, November 9, and November 19. The required daily saline flush was skipped on November 11. Routine catheter care was missed on October 24 and November 24 during day shifts, and on October 24, November 9, and November 24 during night shifts.
Additional flushing treatments ordered for sluggish urine were also missed on November 11.
Licensed Practical Nurse #4 told inspectors that catheter care documentation belonged on the medication administration record. When asked whether undocumented care might have been provided anyway, the nurse was direct: "No, if it is not documented it was not done."
The resident's care plan, updated in August 2024, specifically outlined the catheter requirements. It noted the patient needed an 18 French Coude catheter with a 10cc balloon due to the neurogenic bladder condition. Staff were instructed to watch for infection signs like dark or cloudy urine and notify physicians of any blockages.
The comprehensive assessment from October showed the resident as completely dependent for bathing, transfers, dressing, toileting, and eating. The patient was coded as always incontinent of bowel and requiring the indwelling urinary catheter.
Multiple physician orders addressed the catheter care. A June order required daily output monitoring on both shifts. November orders added the 60ml saline flush requirement and specified suprapubic catheter care twice daily. A November 10 order called for additional 10cc normal saline flushes as needed for sluggish urine, to be provided every shift.
The facility's own catheterization policy stated that licensed nurses would irrigate catheters per physician orders and perform catheter care every shift, documenting all treatments in the medical record.
On December 16, inspectors interviewed the licensed practical nurse about documentation standards. The following day, facility administrators including the administrator, director of nursing, and two assistant directors of nursing were informed of the violations.
Catheter care for neurogenic bladder patients requires consistent attention to prevent complications. The resident's quadriplegia meant complete dependence on staff for this critical aspect of care. Missing multiple treatments over several weeks represented a pattern of inadequate care for a vulnerable patient who relied entirely on nursing staff for basic health needs.
The inspection found no evidence that missed treatments were made up or that alternative care was provided during the documented gaps. Treatment records showed clear absences of required care across multiple shifts and different types of catheter maintenance.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The facility provided no additional information before inspectors completed their review in October 2025.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westport Rehabilitation and Nursing Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
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