The patient at Southfield Wellness Community has neurogenic bladder secondary to multiple sclerosis and lives with a chronic suprapubic catheter that requires regular exchanges. On July 3, a certified nursing assistant discovered something was seriously wrong.
The catheter had exited the urethra and was sitting in the patient's vagina.
Staff C, the registered nurse responsible for the patient's care, confirmed during her interview with inspectors that the catheter was silicone — exactly the type the doctor had specifically ordered staff not to use.
The patient's physician had been explicit in his instructions. After an emergency room visit on July 4 where the obstructed catheter was drained and replaced, the doctor's orders were clear: "Continue every 2-week exchange using catheter (latex or silastic is fine but NOT silicone)."
The emphasis was the doctor's own.
But on July 20, communication reports show staff changed the catheter using "silicone catheter, using sterile technique." The patient experienced "some discomfort with insertion."
Four days later, the patient had dried blood around the catheter site and complained of pain. She told staff she had only a small amount of urine in her bag but was "soaked" that morning. Staff called the clinic.
The doctor saw the patient on July 25 and replaced the catheter himself, again emphasizing his orders: "Plan: Suprapubic tube exchanged today-Continue every two-week exchange using silastic catheter NOT silicone."
By July 29, the patient still had blood around the catheter site and discomfort at the insertion point. When staff called the physician's office, the nurse told them the bleeding was "more than likely from the irritation from the previous catheter."
The doctor's office called back that afternoon. No changes from Friday's appointment, they said, but "it would take time for her to heal due to the previous catheter that was being used."
The patient knew her body well. During her interview with inspectors on September 30, she explained that the nurse had attempted to insert the silicone catheter into her suprapubic site "at least 4 times." The catheter had a square end that "would get caught," she said.
"Resident #3 expressed concerns that the nurse was using the wrong type of catheter and that caused the stoma to get irritated and sore," inspectors wrote. The patient told them she "knows her body very well and that a silastic catheter tubing works the best."
Staff C, the registered nurse, acknowledged during her interview that "a silastic catheter is the type of catheter that the physician ordered for Resident #3." She confirmed she had found the catheter in the patient's vagina on July 3 and verified "it was a silicone catheter" — not the silastic type the doctor had ordered.
The facility's Director of Nursing told inspectors that "staff are expected to follow the physician's orders as directed by using a silastic catheter and not a silicone." She said the facility "followed the standards of practice for following physician orders."
But the medical records tell a different story. Despite clear, repeated physician orders specifying silastic catheters and explicitly prohibiting silicone ones, staff used silicone catheters multiple times. The patient endured at least four insertion attempts with the wrong equipment, causing irritation severe enough to require prescription ointment.
The patient's emergency room visit in July had already revealed the consequences of improper catheter management — the device had migrated from her urethra to her vagina, causing obstruction that required drainage. Yet even after the physician's emphatic written orders, staff continued using the prohibited catheter type.
The woman with multiple sclerosis, dependent on others for this most basic bodily function, repeatedly told staff they were using the wrong equipment. She experienced pain, bleeding, and irritation while her concerns went unheeded.
Federal inspectors found the facility failed to ensure services were provided in accordance with professional standards of practice, citing minimal harm to few residents. The violation occurred despite clear physician orders, patient complaints, and obvious signs of complications from using the wrong medical device.
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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