Federal inspectors found that Hamilton Trace of Fishers staff inserted an indwelling catheter for Resident B on December 20, 2025, but never recorded the required physician's order in his medical record. The facility also failed to document catheter care or monitor urine output as specifically instructed by the resident's doctor.
Resident B suffers from central cord syndrome, a spinal cord injury that causes weakness without paralysis, and neuromuscular dysfunction of the bladder. On December 20, staff discovered he had 855 milliliters of urine retained in his bladder during an evening shift bladder scan. His abdomen was firm from the retention.
The physician's note from that day was explicit about treatment requirements. Staff were to insert an indwelling catheter and monitor the resident's urine output continuously. If output exceeded 600 milliliters, they were to clamp the catheter. The catheter could not be removed until the resident was examined by a physician.
A nursing note from December 21 confirmed that an on-call provider had given orders to insert the catheter and monitor urine output. The note stated the catheter had been "anchored" and that Resident B reported feeling "a lot better."
But the facility's medical records told a different story.
Inspectors found no physician's order for the indwelling catheter anywhere in Resident B's clinical record. There were no treatment orders for catheter care. There was no documentation of urine output monitoring, despite the physician's clear instructions to track output every shift.
The gap persisted for weeks. A physician's order dated December 29 instructed staff to remove the catheter, suggesting it had remained in place for at least nine days without proper documentation or monitoring.
Director of Nursing acknowledged the failures during a January 30 interview with inspectors. He said he could not locate any physician's order for the indwelling catheter in Resident B's record.
"The on-call physician gave the order to the staff during the phone call," he told inspectors. But the verbal order was never properly documented.
The nursing director also revealed a troubling gap in the facility's monitoring practices. He said staff only recorded urine output amounts when specifically ordered by a physician to do so. He was unaware of the physician's December 20 note requiring continuous output monitoring.
Federal regulations require catheter care to be provided and documented every shift for residents with indwelling catheters. Hamilton Trace failed to meet this basic standard.
The violation represents more than paperwork problems. Proper catheter monitoring prevents serious complications including urinary tract infections, kidney damage, and bladder injury. For residents like Resident B, who cannot control their bladder function due to neurological damage, consistent monitoring becomes critical for preventing medical emergencies.
Resident B's case began with a medical crisis - 855 milliliters of retained urine and abdominal firmness that required immediate intervention. The physician provided clear, specific instructions to prevent the situation from recurring.
The facility's response was to insert the catheter as ordered, but then abandon the monitoring requirements that would have protected the resident from future complications.
When inspectors arrived more than a month later, the nursing director still could not locate the basic physician's order that authorized the catheter in the first place. The required daily documentation of catheter care was missing. The urine output monitoring that the physician had specifically ordered was never implemented.
Resident B reported feeling better after the catheter insertion, according to nursing notes. But without proper monitoring and documentation, there was no way to verify his condition remained stable or to catch problems before they became emergencies.
The inspection occurred following a complaint, suggesting someone noticed the deficient care and reported it to state authorities. Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents.
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.