Complaint Investigation Report

Medical record review revealed on 11/24/2025, resident one, (R1) presented to the Emergency Department (ED) with suspected complications from a chronic suprapubic catheter. Medical records suggest R1 experienced stomach pains and her catheter was not sufficiently draining in the days leading to her hospitalization. R1, who had a history of Urinary Tract Infections (UTIs) experienced irregular bladder wall thickening, hematuria, and blood clots in her catheter resulting in her becoming septic and ultimately passing from cardiopulmonary arrest. Staff reported changing and cleaning R1’s catheter bag and lines twice daily per doctor’s directions.

Facility records show that every catheter change and cleaning was marked as completed for

the month of November (2025). Urologic records confirm that staff took R1 to her monthly

medical appointments in the months leading up to her passing. Furthermore, the medical

records reflect that staff consulted with medical staff after observations of light bleeding into the

catheter bag and issues with draining which were addressed or dismissed by medical staff.

There is insufficient evidence to suggest that neglect or lack of care and supervision led the

development of an infection and subsequent death.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated .