The incident at Woodlands Place Rehabilitation Suites violated the facility's own policy requiring notification of family members when treatment plans change significantly. The patient's family held power of attorney and was visiting another relative just down the hall when staff placed the catheter without their knowledge.
Resident #2 had been repeatedly asking to use the bathroom due to his enlarged prostate. RN-A said he had been taken to the bathroom multiple times in 30 minutes. She called the doctor and received orders for an "in and out" catheter, then asked LVN-B to insert it since the resident was on her hall.
When RN-A checked back, LVN-B hadn't placed the catheter. So RN-A explained the procedure to the resident and inserted it herself. The resident said it was hurting, but RN-A told him it would hurt because of his enlarged prostate.
Neither nurse contacted the family first.
"One thing they did wrong was nobody called the family first," RN-A told inspectors on December 23. "I assumed LVN-B had called the family and vice versa."
LVN-B saw it differently. She said she received a text from RN-A about the doctor's orders but didn't place the catheter herself. "She was not the nurse who requested the order and did not put the catheter in, so she did not feel she was responsible for notifying the family," according to the inspection report.
The family discovered what happened later. The patient's representative said she didn't understand why the facility hadn't called before placing the catheter, especially since family members with power of attorney were in the building at the time.
"Resident #2 had felt like he had to use the restroom the entire time he had been at the facility due to his enlarged prostrate," the family member told inspectors. She explained that the resident had dementia and didn't remember many things.
The administrator acknowledged that staff normally would have called the family before placing a catheter. He said a family member with power of attorney was visiting another relative in a room on the next hall during the incident.
Both nurses were written up for failing to contact the family.
RN-A told inspectors she would usually call family members after receiving doctor's orders, "but did not usually call to get permission to insert a catheter." She said she assumed LVN-B had called because it was her resident, and noted that the patient's family was always in the building.
When inspectors interviewed the resident the next day, he said he had no problems with staff. He nodded yes when asked if he was going home and then fell asleep during the interview.
The facility's own nursing policies require staff to notify patients and their representatives about changes in medical condition or treatment plans. The admissions handbook specifically states that facilities must notify resident representatives when "it is necessary to alter treatments significantly."
The administrator confirmed to inspectors that the family should have been called regarding the doctor's order.
LVN-B was written up on December 22, the day after the incident. She maintained that she wasn't responsible for the notification since she didn't request the order or insert the catheter.
The breakdown in communication occurred despite clear facility policies and the family's presence in the building. Two family members held power of attorney for the dementia patient, but neither was contacted before staff inserted the catheter to address his prostate-related bathroom difficulties.
Inspectors attempted to reach the physician who ordered the catheter but received no response to voice messages and texts left on both his office and cell phone numbers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodlands Place Rehabilitation Suites from 2025-12-23 including all violations, facility responses, and corrective action plans.
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