Pelican Health Randolph: Catheter Care Failure - NC
Federal inspectors cited Pelican Health Randolph LLC following a September 2025 complaint investigation, finding that staff failed to follow a physician's order and care plan for a catheter leg anchor for a resident identified in records as Resident 5. The resident was under urological care for chronic urinary tract infections and neurogenic bladder, a condition that had already made the catheter a long-term fixture of the person's care.
The medical director explained to inspectors why he wrote the order in the first place. A full urinary collection bag creates tension on the catheter tubing. That tension, especially during repositioning, can pull on the urinary opening, risking trauma to the urethra or dislodging the catheter entirely. A full bag also raises the risk of stagnant urine flowing backward into the bladder. The anchor was ordered to prevent all of that.
The nurse aide assigned to Resident 5, identified as NA 3, told inspectors during an interview on September 10 that he emptied the urine collection bags during rounds every two hours and always emptied the bag before transferring the resident to reduce tension on the tubing. He said he had not noticed a securement device in place and had simply made sure the tubing wasn't pulling on the resident's urinary opening. He was working around the problem without knowing the solution had already been prescribed.
The device was available. Central Supply had it. No nurse had retrieved it or delegated the task to an aide.
The Director of Nursing, who told inspectors that September 10 was her first day in that role after joining the facility in October 2024, was direct about what should have happened. The nurses were expected to follow medical orders and care plans. Since Resident 5 had both an order and a care plan calling for a catheter anchor, a nurse should have placed it or assigned the task to an aide.
The nurse practitioner who had been following Resident 5 since January 2025 told inspectors by phone on September 15 that the resident had not experienced catheter dislodgement during that period. That fact offered some reassurance about immediate harm. But it did not explain how a standing physician's order went unexecuted for months while staff managed the catheter without the protection the doctor had specifically prescribed.
Inspectors rated the violation at the level of minimal harm or potential for actual harm, and noted that few residents were affected. The deficiency fell under federal standards requiring nursing homes to follow physician orders and ensure residents receive proper treatment and care consistent with their care plans.
The gap between what was ordered and what was done ran through every layer of the facility's care structure. The physician wrote the order. The care plan reflected it. The supply room stocked the device. The aide emptying the bag every two hours had no idea an anchor had been prescribed. The nurses responsible for executing or delegating the order had not done so.
The nurse practitioner's observation that no dislodgement occurred does not resolve what the medical director described as an ongoing risk, one that increases every time a full bag adds tension to the tubing and every time staff reposition a resident without the anchor in place. The catheter remained unsecured for as long as the order went unfollowed, and the order had been in place well before the complaint that triggered the inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health Randolph LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Pelican Health Randolph LLC in Charlotte, NC was cited for violations during a health inspection on September 17, 2025.
The medical director explained to inspectors why he wrote the order in the first place.
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.