The resident was transferred to the hospital afterward to rule out a urinary tract infection.
Resident #572 had been living at the 70-bed facility with multiple serious conditions including bacteremia, chronic kidney disease, and neuromuscular dysfunction of the bladder. She had intact cognitive function but was always incontinent and dependent on staff for all daily activities.
The resident had an indwelling Foley catheter due to a neurogenic bladder, according to her care plan. Staff were supposed to monitor for pain or discomfort from the device.
On one afternoon at 2:47 P.M., a nurse contacted urology seeking an order to remove the resident's catheter. But no return call came. No orders were received.
Later, the resident told a nurse she was experiencing severe urinary pain. She rated the pain as nine out of 10.
The nurse gave pain medication. Then the nurse removed the catheter because the resident requested it.
The resident was transferred to the hospital to rule out a urinary tract infection.
The Director of Nursing confirmed during an interview that no physician order could be found in the medical record authorizing removal of the catheter.
The facility's own bladder management protocol, revised earlier that year, was clear about requirements. Staff must confer with a provider and obtain an order for indwelling urinary catheters when indicated. A physician's order is needed for catheter insertion.
The protocol specifically states that if a registered nurse is uncertain about whether to remove a catheter, the provider must be contacted.
The nurse had already tried to reach urology earlier that day but received no response. Despite this, and despite the facility's written protocol requiring physician orders, the catheter was removed based solely on the resident's request for pain relief.
Federal inspectors classified this as a minimal harm violation affecting few residents. They reviewed six residents with urinary catheters during their complaint investigation and found this single case where proper procedures weren't followed.
The resident later died under hospice care, though the inspection report doesn't indicate this was related to the catheter incident.
Urinary catheters require careful medical oversight because improper insertion or removal can lead to infections, bleeding, or other complications. Residents with neurogenic bladders like #572 often need catheters because their bladder muscles don't function normally, making it difficult or impossible to urinate naturally.
The pain the resident experienced could have indicated several problems requiring medical evaluation before catheter removal. Severe catheter-related pain might signal infection, blockage, or other issues that need physician assessment rather than immediate removal.
The facility's protocol existed precisely to prevent this situation. By requiring provider contact when nurses are uncertain about catheter removal, the policy was designed to ensure medical decisions about catheter management involve appropriate clinical oversight.
The nurse's decision to remove the catheter after giving pain medication, while responding to the resident's distress, bypassed the medical evaluation that might have determined the underlying cause of the severe pain.
The subsequent hospital transfer to rule out urinary tract infection suggests medical staff recognized the need for further evaluation after the catheter was removed. This transfer might have been avoided if the catheter removal had been delayed pending physician consultation about the resident's pain.
The inspection finding emerged during a complaint investigation, indicating someone had raised concerns about care at the facility that prompted federal scrutiny.
Franciscan Care Center Sylvania now faces questions about whether staff understand when physician orders are required and whether the facility's protocols are being consistently followed for medical procedures.
The case illustrates the tension healthcare workers face between responding immediately to resident distress and following established medical protocols designed to ensure safe care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Franciscan Care Ctr Sylvania from 2025-11-20 including all violations, facility responses, and corrective action plans.