Hamilton Trace: Urinary Care Violations - IN
The resident, identified in inspection documents only as Resident B, had central cord syndrome, a spinal injury that causes significant weakness, and had lost control of his bladder as a result. On December 20, 2025, a bladder scan showed he was holding 855 milliliters of urine. The physician was contacted, and the plan was clear: place an indwelling catheter, monitor his urine output, and clamp the catheter if output exceeded 600 milliliters. Do not remove it until he had been seen in person by a doctor.
A nursing note the following day confirmed the catheter had been anchored and that Resident B said he was feeling much better.
None of what came next was documented properly.
Inspectors reviewing Resident B's clinical record on January 30, 2026, found no written physician's order for the indwelling catheter. There were no treatment orders covering catheter care. There was no record of urine output being monitored. The physician's December 20 note described a detailed care plan. The patient's chart contained almost none of it.
The Director of Nursing, interviewed that afternoon, confirmed he could not locate a physician's order for the catheter. His explanation: the on-call physician had given the order verbally by phone. It was never transcribed into a formal order.
On the question of urine output monitoring, his answer was more troubling. Staff, he said, did not record urine output amounts unless a physician had specifically ordered them to do so in writing. The physician had ordered it, in writing, in his December 20 note. The Director of Nursing said he was unaware that note existed.
The December 20 physician's order that preceded all of this, the one dated before the retention crisis, had directed staff to bladder scan Resident B every shift and contact the medical provider if retained urine exceeded 200 milliliters. That threshold existed because his condition, a neurogenic bladder caused by the spinal injury, made retention a recurring and serious risk. Urine retention at high volumes can cause bladder damage, infection, and in severe cases, a dangerous spike in blood pressure in patients with spinal cord injuries.
The catheter was eventually ordered removed on December 29, 2025, nine days after it was placed. What happened to Resident B's urine output during those nine days, whether the catheter was ever clamped as the physician directed, whether output ever exceeded the 600-milliliter threshold that was supposed to trigger an intervention, none of that appears in his chart.
Inspectors cited the facility for failing to provide catheter care, monitoring, and documentation of urine output. The level of harm was classified as minimal harm or potential for actual harm.
What the record shows is a gap between what a physician ordered and what staff understood themselves to be doing. The doctor wrote a care plan. The nursing staff anchored the catheter and noted the resident felt better. Then, for the duration of the catheter's placement, no one tracked what it was draining.
Resident B told staff on December 21 that he was doing a lot better. Whether that held for the nine days that followed, and what his bladder was doing during that time, Hamilton Trace of Fishers cannot say. The records do not exist.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hamilton Trace of Fishers from 2026-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
HAMILTON TRACE OF FISHERS in FISHERS, IN was cited for violations during a health inspection on January 30, 2026.
On December 20, 2025, a bladder scan showed he was holding 855 milliliters of urine.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.