The 78-year-old woman with moderate mental impairment had been admitted to Autumn Creek Post Acute with the catheter already in place. She used a walker and needed moderate help from staff to stand, transfer to chairs or beds, and walk to the bathroom.
When Registered Nurse A documented the fallen catheter in an alert note at 11:28 am that Tuesday, no one called the physician. No one assessed whether the resident still needed the device. No one developed a plan for how she would manage bladder function without it.
The next day, nursing notes simply stated the catheter had been "discontinued."
But there was no doctor's order to discontinue it. The facility's Director of Nursing confirmed during the October inspection that "there should have been" a physician's order.
RN A told inspectors the catheter was never replaced "because there was no indication or diagnoses to support the use of a catheter." Yet the nurse could not provide evidence that anyone had notified the physician about the fallen device or obtained an order to discontinue it.
The resident had been continent with bowel movements but depended on the catheter for bladder control. After it fell out, she would need to use the toilet instead.
Staff provided no bladder training.
RN A explained that when a catheter is removed, residents should be placed on "Alert Charting" — nursing assessments every eight hours to watch for bleeding or urinary retention, where urine stays trapped in the bladder.
No such monitoring occurred. Inspectors found no alert charting in the resident's records after August 14.
The facility also failed to complete required assessments. Staff never evaluated whether the resident still needed the catheter. They never assessed her bladder status after removal. They never developed a bladder training program.
The Director of Nursing acknowledged during the inspection that she "was not aware of an assessment to determine the need for an indwelling catheter." She confirmed no bladder assessment or training had been done "and there should have been."
Care planning failures compounded the medical oversights. The facility never created a baseline bowel and bladder care plan, which should be completed within three days of admission. They never developed an individualized bladder training program to help the resident transition from catheter dependence to independent toileting.
The Director of Nursing confirmed there was no care plan addressing "interventions needed to restore bladder function."
RN A told inspectors that bladder training hadn't been provided because "the physician had not ordered it." But the physician was never informed the catheter had fallen out in the first place.
The resident's admission assessment had documented her functional limitations. She scored 10 out of 15 on cognitive testing, indicating moderate mental impairment. She needed moderate assistance with basic mobility tasks like standing and transferring.
These factors would typically require careful planning when transitioning from catheter use to independent toileting. Residents with cognitive impairment and mobility limitations face higher risks of falls, incontinence, and urinary tract infections without proper bladder training.
Federal regulations require nursing homes to provide necessary care and services to maintain each resident's highest practicable physical, mental, and psychosocial well-being. This includes appropriate medical device management and bladder training when catheters are removed.
The inspection found the facility failed to notify the physician when medical equipment failed, failed to obtain proper orders for care changes, failed to assess the resident's ongoing needs, and failed to provide required training and monitoring.
The violation affected few residents but posed potential for actual harm. Improper catheter management can lead to urinary tract infections, bladder dysfunction, falls from rushed bathroom trips, and loss of dignity from incontinence episodes.
The resident's August progress notes contained no documentation explaining why the catheter wasn't replaced and no charting about her condition after its removal. The medical record gap lasted from August 14 through the inspection in late October.
Staff decisions about the resident's bladder care were made without physician input, proper assessment, or individualized planning. The facility's Director of Nursing confirmed multiple care failures during the inspection but provided no timeline for correcting the deficiencies.
The resident remained at the facility during the inspection, still without the catheter that had fallen out more than two months earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Creek Post Acute from 2025-10-27 including all violations, facility responses, and corrective action plans.