The woman, identified as Resident #3 in federal inspection records, has multiple sclerosis, diabetes, and a history of sepsis. She requires an indwelling catheter due to neurogenic bladder, a condition where nerve damage disrupts normal bladder function. Her care plan specifically called for monitoring signs of urinary tract infections and catheter complications.
Documentation shows the resident had no urinary output during multiple shifts between July 1st and July 4th. Night shift staff recorded zero output on July 1st, 3rd, and 4th. Day shift documented the same on July 2nd and 3rd.
Nobody acted for two full days.
On July 3rd at 4:36 PM, nursing assistants finally reported to the registered nurse that the resident "has not had any output in her catheter drainage bag for the last 2 days and has been very wet/incontinent of urine." The nurse discovered the catheter balloon had deflated and found "deep dark red blood" in the tubing.
The nurse replaced the catheter but obtained only a small amount of urine. Clinical staff recommended emergency room evaluation if the resident developed fever, significant bleeding, or substantial pain.
By the next morning, the situation had worsened. The resident's brief was "drenched" and she had very little catheter output. When staff asked if she wanted to go to the emergency room, she said yes. The facility transported her in their van.
Hospital doctors diagnosed obstruction of the suprapubic catheter and placed a new one. The resident returned to the facility the same day with a diagnosis of urinary retention caused by the blocked catheter.
During interviews with federal inspectors in September, the resident confirmed she had experienced no urinary output for two days and suffered pain and discomfort before requesting emergency treatment.
Staff C, a registered nurse, told inspectors it was "the expectation of the staff to notify if no urinary output after one shift." The facility's Director of Nursing acknowledged the resident had gone two days without catheter output and confirmed staff should notify the charge nurse at the end of their shift if a resident has no urinary output.
The facility's own standards required immediate notification after just one shift of no output. Yet documentation shows staff recorded zero output across five separate shifts over two days before taking action.
For a resident with neurogenic bladder and chronic urinary tract infections, a blocked catheter represents a serious medical emergency. Urine backing up into the kidneys can cause permanent damage or life-threatening infections, particularly dangerous for someone with the resident's complex medical history including previous sepsis.
The resident's care plan specifically identified her as "at risk for complications related to chronic urinary disturbance" and called for monitoring pain and discomfort related to catheter use. The plan required staff to "observe for signs and symptoms of UTI" and ensure proper medication administration.
Multiple staff members documented the lack of output but failed to escalate the situation. The resident became incontinent, soaking through protective briefs as urine bypassed the blocked catheter. She experienced mounting discomfort while staff continued routine documentation without intervention.
When the nurse finally examined the catheter on July 3rd, the discovery of deflated balloon and blood in the tubing suggested the blockage had been building pressure in the system. The minimal urine output after catheter replacement indicated significant retention had already occurred.
The facility operates 56 beds and identified this as an isolated incident affecting one resident. However, the breakdown occurred across multiple shifts and involved several staff members who documented the problem without acting on established protocols.
Federal inspectors classified this as a violation of providing appropriate treatment according to medical orders and resident needs. The inspection found the facility failed to assess a resident with no catheter output for two days, resulting in emergency department treatment for discomfort.
The resident confirmed to inspectors that she experienced pain and specifically requested emergency room care after two days of catheter dysfunction. Her request came only after she had endured the discomfort and staff finally acknowledged the severity of her condition.
Hospital records documented the obstruction as the primary reason for her emergency visit, confirming the facility's delayed response had created a preventable medical crisis for a vulnerable resident with multiple chronic conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Southfield Wellness Community from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
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