The incident occurred on August 1, 2025, when the night nurse discovered blood in Resident #1's catheter bag but failed to contact the doctor. The resident had a foley catheter that drained to gravity and was known to frequently pull at the device.
Federal inspectors found the delayed reporting violated standards for physician notification during a complaint investigation at Center at Zaragoza on November 25, 2025.
The facility's Director of Nursing acknowledged the severity of the oversight during a telephone interview. "Blood in urine should have been reported to the physician by the night nurse that first noticed it and then followed up on it by the day shift nurse," she told inspectors at 12:40 p.m.
She explained that reporting depends on the type of change observed, such as alterations in consciousness level and vital signs. But blood in urine clearly warranted immediate physician contact.
"It was important for a change of condition to be reported to the physician in a prompt manner because if it was not then it could affect the resident's health overall, and it was also important to know that interventions apply," the Director of Nursing said.
The nursing director could not recall whether the night nurse had actually called the physician about the bloody urine. She stated that nurses were responsible for reporting condition changes to the physician, oncoming shift, charge nurse, and herself.
When asked about staff training, she said she had conducted in-service education on reporting condition changes to physicians but could not remember when.
The facility administrator was unaware of the August 1 incident when inspectors interviewed him at 1:20 p.m. He confirmed that Resident #1 disliked the foley catheter and would frequently pull at it, but said he had no knowledge of the blood in urine episode.
"The expectations for the nurses were to notify the physician promptly of any changes of condition and for the nurses to follow the doctors' instructions and document everything done," the administrator told inspectors.
He emphasized the potential consequences of delayed reporting. "The risk of not notifying the doctor promptly was a potential for a decline in residents medical condition."
The administrator placed responsibility squarely on floor nurses. "It was the responsibility of the floor nurses to ensure that they were reporting anything out of the ordinary to the doctor."
He said the facility's most recent in-service training on reporting condition changes had occurred in August 2025. Inspection records confirmed the Director of Nursing had completed this training on August 6, 2025 — just five days after the unreported bloody urine incident.
The facility's written policy on condition changes, last reviewed on April 2, 2024, clearly outlined nursing responsibilities. According to the policy, nurses must evaluate and document all active diagnoses and notify physicians when specific signs and symptoms are identified.
The policy specifically required nursing staff to notify the physician if any concerning signs and symptoms were identified during patient assessment.
Despite having clear policies and recent training, the communication breakdown on August 1 represented a failure in the basic nursing responsibility to keep physicians informed of changes that could affect resident health.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the incident highlighted systemic communication issues that could impact patient safety facility-wide.
Blood in urine can signal various medical conditions requiring prompt evaluation, from urinary tract infections to more serious complications. For a resident already struggling with catheter tolerance and frequently manipulating the device, immediate physician notification becomes even more critical.
The August timing proved particularly troubling given that the facility conducted condition-change training just days later, suggesting administrators were already aware of reporting deficiencies among nursing staff.
The case underscored the gap between written policies and actual practice at the El Paso facility, where clear protocols existed but failed to prevent a basic communication failure that could have endangered resident health.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Center At Zaragoza, LLC from 2025-11-25 including all violations, facility responses, and corrective action plans.