**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, facility investigation, and policy review, the facility failed to ensure one of four residents (Resident (R) 4) was free from neglect when staff failed to provide timely and competent care in response to complaints of pain and decreased urinary output of 20 sample residents. As a result, R4, who had a neurogenic bladder and an indwelling catheter, experienced severe pain, and improper placement of an indwelling catheter. Findings include:Review of the facility's policy titled, Freedom From Resident Abuse, Neglect, Mistreatment & Exploitation, dated 06/24 documented, Each resident at the [Facility Name], Idaho State Veterans Homes (ISVHs) has the right to be free from verbal, sexual, physical, and mental abuse; neglect; exploitation; mistreatment including injuries of unknown source; misappropriation of resident property; involuntary seclusion, and crime against a resident.NEGLECT means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be the result of a [NAME] of failures or may be the result of one or more failures involving a covered individual and a resident(s).Review of R4's significant change in condition Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/15/25, located under the MDS tab in the electronic medical record (EMR), revealed the facility admitted R4 on 05/03/24. R4 had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which indicated R4 was moderately cognitively impaired. R4 required total dependence on toileting and personal hygiene and had an indwelling catheter. R4's pertinent diagnosis included neurogenic bladder.Review of R4's care plan, last revised on 04/15/25, located under the Care Plan tab in the EMR, revealed R4 had an indwelling catheter related to a diagnosis of neurogenic bladder. The care plan interventions indicated R4 had a 16 French catheter with a 10-millimeter (ml) [balloon] and directed staff to change and care for the indwelling catheter per the physician's orders. The care plan also directed staff to assess R4 for signs and symptoms of urinary tract infections, such as changes in urine color, consistency, and odor; behavioral changes, altered vital signs, pain/flank pain, burning, chills, and altered mental status.Review of the Medication Administration Audit Report, dated 10/25/24, provided by the facility, revealed the following pertinent orders:-Lidocaine (local anesthetics) external patch 4 %. Apply to [R4's] back topically one time a day for pain and remove per schedule.-Acetaminophen (pain reliever/fever reducer) oral tablet. Give 1000 milligrams (mg) by mouth three times a day for pain.-Buprenorphine HCl (opioid medication) sublingual tablet 2mg. Give one tablet sublingually three times a day for pain every eight hours.-Methocarbamol (muscle relaxant) oral tablet 1000mg. Give 1000 mg by mouth three times a day for muscle spasms for two Days (10/23/24 - 10/24/24).-Methocarbamol (muscle relaxant) oral tablet 750mg. Give 750 mg by mouth three times a day for muscle spasms (start 12/25/24).-Indwelling Foley catheter [size of the catheter and balloon was not noted]. -Monitor catheter anchor point and tubing to ensure no kinking, blockage, or pain at the insertion site.-Indwelling Foley catheter, change every three months on the first of the month, and PRN (as needed) for malfunction.Review of the provider's Skilled Nursing Follow Up Note, dated 10/22/24 at 8:15 AM, located under the Miscellaneous tab in the EMR, revealed R4 seen for routine follow-up on chronic conditions. R4 reports worsening pain to mid/low back, ongoing for the last 1-2 weeks. Pain seems to grab him. No radiculopathy or other pain in the legs today. He is lying down in bed this morning due to the pain. No recent falls or other injury.Exam: Elderly. Well nourished. Lying down in bed. Abdomen: positive bowel sounds. Soft, hernia is noted. Protuberant. GU: catheter in place, straw-colored urine. Assessment and Plan: Chronic pain syndrome, low back pain, peripheral neuropathy. On gabapentin, Robaxin, Buprenorphine, Tylenol, and a lidocaine patch. Son does not want the pt [patient] to take further opioid medications, given prior history. Today, pain seems to stem from low back grabs/muscle spasms. Will increase Robaxin to 1g three times a day for two days, then reduce to 750mg three times a day routine. Also, referring to pain management, will also ask about heat packs by physical therapy. Continue to monitor.Review of R4's Alert Charting Progress Note, dated 10/22/24 at 9:58 PM, located under the Progress Notes tab in the EMR, revealed Licensed Practical Nurse (LPN) 5 noted Methocarbamol l000mg three times a day for two days for back pain. Action taken: Will monitor.Review of R4's Alert Charting Progress Note, dated 10/23/24 at 3:50 PM, located under the Progress Notes tab in the EMR, revealed Registered Nurse (RN) 9 noted an increase in Robaxin (Methocarbamol). Resident complains of severe pain to [his] lower back this morning, requested to get back in bed, did receive new dose of Robaxin, has not alleviated pain as of this time. Action Taken: Continue to monitor.Review of R4's Alert Charting Progress Note dated 10/23/24 at 9:50 PM, located under the Progress Notes tab in the EMR, revealed the resident complained of back pain this shift, administered medications as ordered. Action taken: Will monitor.Review of R4's Alert Note, dated 10/24/24 at 6:15 AM, located under the Progress Notes tab in the EMR, revealed a Certified Nursing Assistant (CNA) alerted RN9 to a change in R4's condition. RN9 found R4 hyperventilating, tachycardic, diaphoretic, short of breath, vomiting, and reporting epigastric and severe lower back pain. R4's HR [heart rate] > [greater than] 130 [beats per minute (BPM)], R [respirations] 50 [breaths per minute (BPM)], O2 [oxygen saturation] 91% [on] 5LPM [liters per minute (LPM)]. R4 noted with blurry vision, able to communicate [his] needs, denied chest pain, denied headache, yelling he needed to pee, has an indwelling catheter in place, tubing was kinked, tubing removed to drain bladder that alleviated the distress. AT 6:45 AM, vomiting had stopped, diaphoresis resolved, and vitals showed improvement (BP [blood pressure]166/93, HR 108, RR [respiratory rate] 34, O2 94%). R3, who has a history of atrial fibrillation (A-fib), was able to take oral Diltiazem ER [calcium channel blocker used to control rapid heartbeats or abnormal heart rhythms] and sublingual Buprenorphine (opioid pain reliever). R4 declined transfer to the hospital for further evaluation. At 7:10 AM, further improvement noted (BP 149/87, HR 107, RR 28, O2 94%). Methocarbamol (muscle relaxant) administered for pain. At 7:20 AM, RN9 updated the on-call provider, who ordered continued monitoring at the facility and PRN [as needed] Metoprolol Tartrate (beta blocker used to treat high blood pressure) 12.5mg (milligrams) for HR >120 bpm. AT 9:25 AM, RN9 noted that R3 was calmer, reported decreased pain, and had a regular breathing pattern. Vitals: BP 134/82, HR 100, RR 28, O2 91% on 5LPM. Continuing to monitor at this time. Review of R4's Alert Charting Progress Note, dated 10/24/24 at 4:05 PM, located under the Progress Notes tab in the EMR, revealed RN9 noted R4 complained of pain at an eight out of 10. RN9 administered a new dose of Robaxin (methocarbamol) with minimal relief. RN9 noted, continue to monitor and give medications per the physician's orders. Action taken: Will monitor.Review of R4's Alert Charting Progress Note, dated 10/24/24 at 9:46 PM, located under the Progress Notes tab in the EMR, revealed R4 complaining of increased back pain; medications administered as ordered. Action taken: Will monitor.Review of the Medication Administration Record (MAR) dated 10/24, located under the Orders tab in the EMR, revealed that on 10/25/24, RN6 administered the following routine medications to R4 at 8:34 AM: Buprenorphine HCl 2 mg sublingual tablet, Acetaminophen 500 mg tablets (two), Xopenex HFA Inhalation Aerosol 45 mcg/act (two puffs), Lidocaine 4% external patch applied topically to the back. At 8:35 AM: Lamictal 75 mg tablet, Metformin HCl 500 mg tablet, Celexa 20 mg tablet, -Diltiazem HCl ER 180 mg tablet, Eliquis 5 mg tablet, Simethicone 80 mg chewable tablet, Tiotropium bromide monohydrate inhalation capsule 18 mcg, Fluticasone-salmeterol inhalation aerosol powder, breath-activated 500-50 mcg/act, Albuterol sulfate nebulization solution (2.5 mg/3 ml) 0.083%, 3 ml, and Methocarbamol 750 mg tablet.Review of R4's Alert Note, dated 10/25/24 at 9:12 AM, located under the Progress Notes tab in the EMR, revealed the Previous Director of Nursing (PDON) documented, Late entry Per CNA alert charting: On about 9 AM on 10/25/24 while giving a brief change resident indicated his right side of his stomach was hurting and that he was feeling severe pressure in his belly. As we were changing him nurse in [sic] shift came in and she assessed him.Review of R4's Alert Note, dated 10/25/24 at 4:06 PM, located under the Progress Notes tab in the EMR, revealed a V.O. (verbal order) from R4's PA (Physician's Assistant) to send the resident to acute care for further workup of abdominal pain, no urine output, and pain in the pelvis. The resident's son called and was notified at approximately 10:06 AM. 91l called at approximately 9:59 AM. The resident left with AMR [American Medical Response] at 10:39 AM.Review of the Bladder Activity Report, dated 10/15/24 through 10/25/24, provided by the facility, revealed the following documented urinary outputs in cubic centimeters (cc)-10/22/24 at 5:59 AM: 1000cc/5:50 PM: Not noted. Note stating, Response Not Required. -10/23/24 at 5:59 AM: 1875cc/5:17 PM: 1200cc (total 3875cc)-10/24/24 at 5:59 AM: 850cc/5:59 PM: Not noted. Note stating Response Not Required. -10/25/24 at 5:55 AM: 3500ccReview of the Emergency Department (ED) Encounter Note, dated 10/25/24 at 12:17 PM, located under the Miscellaneous tab in the EMR, revealed R4 presented to the ER (emergency room) with worsening abdominal pain and distention. He comes from assisted living facility [nursing home] where apparently, they tried to replace his Foley catheter had a lot of difficulty and pain and no urine output. Here we are seeing that the balloon is most likely inflated within the prostate and not the bladder, and this was removed with improvement of symptoms. He has no urinary retention on ultrasound. CT [Computerized Tomography] abdomen pelvis without acute findings other than incidental right lower lobe pneumonia now seen on chest x-ray. He has leukocytosis. He has neurogenic bladder, we placed a coude catheter and his urinalysis is a nitrite positive UTI [urinary tract infection]. The patient would benefit from observation admission for IV [intravenous] antibiotics for UTI and incidental right lower lobe pneumonia.Review of the facility's investigation, dated 10/25/24 through 11/01/24, provided by the facility, revealed that on 10/25/24 at approximately 11:00 AM, the Abuse Response Team received an allegation of neglect by staff. RN3 and LPN4 reported to the [Nursing] Home Administrator that RN6 left a resident (R4) who was unable to void bladder and in pain of 10 out of 10 to go on a 15-minute break. RN3 and LPN4 responded to screams from R4's room to assess the situation. Upon finding him in distress and showing signs of being in pain, they contacted 911.During an interview on 07/30/25 at 4:24 PM, attempts to review the facility's surveillance video from 10/25/25 proved unsuccessful. The Administrator stated that the facility no longer had the surveillance video because their retention policy was for only 30 days. The Administrator stated that the cameras were only in the corridor and on 10/25/24 showed RN6 exited through one door and returned from a smoke break.Review of RN6's handwritten statement, dated 10/25/24 at 11:16 AM, provided by the facility, revealed that RN6 went to assess R4 with complaints of 10 out of 10 pain. Upon assessment, RN6 found that R4's indwelling catheter was not draining. Upon further assessment, RN6 realized he hadn't urinated in more than 24 hours. Foley flushed without effectiveness. The indwelling catheter was completely changed, resulting in no urine output. Pain pill Buprenorphine given sublingually. R6 was still in 10/10 pain. RN6 told CNA12 and CNA14 that she was going to take a 15-minute break while she allowed the pain medication kick in so R6 would vasodilate. Then she could reassess R6's urinary output and proceed with an emergency room trip if applicable.Review of RN6's verbal statement, dated 10/28/24, provided by the facility, revealed that On Monday, October 28, 2024, at approximately 1510 (3:10 PM), [RN6] provided a verbal statement to the primary investigator [SW2] and [RN1], RN Manager, regarding the allegation of neglect. RN6 was asked about the day she provided care for [R4]. RN6 stated she showed up at 0600, attended a mandatory meeting at 0630, and then went to the floor between 0730 and 0800. She stated [CNA12], [CNA13], and [CNA14] came and got her, explaining [R4] was in 10/10 pain. [RN6] immediately went to assess him. Upon evaluation, his stomach was distended, and no urine was found in his catheter bag. RN6 obtained a 10CC [six] catheter, then attempted to flush [R4's] catheter; however, the fluid splashed back on her, and [RN6] stated the flush was unsuccessful. She states a new Cath kit and foley were pulled out to completely change his catheter. [RN6] explained she texted [name of the previous director of nursing's name], DNS [Director of Nursing Services], around 0900 asking if the bladder scanner was broken but never received a response. The catheter was changed using a 10CC [sic] balloon, but [R4] was still in pain with no urine output. [RN6] explains she went to get [RN4's] pain pill, Buprenorphine, checking it out of the narcotics box on the med cart. She got all his other pills at this time, including gabapentin and Tylenol giving him all the medications all at once. [RN6] reiterated multiple times [that] all the CNAs were present for the pain medications being given, specifically being placed under his tongue. She provided education on the importance of relaxing and talked him through breathing exercises. [RN6] explained to [R4] she was going to give him time to allow for the pain medication to work then come back in to reassess. After, she told [CNA12], [CNA14], and [CNA13] she was taking a l5-minute break, then would reassess him for urine output, but to be prepared that if there wasn't any, she would ship him out. [RN6] explained on her way to break, she stopped in because [previous director of nursing's name] hadn't answered her about the bladder scanner. She wanted the information from a scan to give to the EMTs. [previous director of nursing's name] stated that it was broken. [RN6] stated she was asked multiple questions regarding her process and what procedures she had completed to which she answered. Upon returning from break, she put all her stuff down and was told paramedics were on the way and paperwork was all filled out. [RN6] alleges that she then asked [RN3] what happened and if she had a doctor's orders to discharge [R4] to the ER and [RN3] allegedly stated that, I [RN3] don't give a f***. [RN6] then proceeded to explain she is frustrated due to not being asked about what happened prior to going on break. [RN6] explained she has been a nurse for 26 years and that [RN3] and [LPN4] are brand new nurses and do not have the experience.Further review of the nurse's verbal statement, provided by the facility, revealed that staff asked RN6 the following questions: -When you came into clinicals, you indicated you needed a bladder scanner. When told it was broken, you stated [that] you needed to ship R4 to the ER and call 911. Can you tell me when you placed that call? RN6 stated that she didn't place it. She explained she was going to place the call if needed, which would have been determined after coming back from break and reassessing to see if the pain pill worked. She explained LPN4 and RN3 made the call before she had the ability.-You stated there was no urine output for 24 hours. How did you make that determination? RN6 answered the CNAs told me from night shift the night prior. Then CNA12 talked to me about not having any during that specific shift. CNA18 stated that on pass-down from the night shift, CNA13 had worked the day before and gave her that pass-down.-How did you determine the proper placement of the catheter before the balloon was inflated? RN6 answered by stating, There are a couple different ways to do it. If there was urine output, or you can put a stethoscope up [to] his bladder to listen to the whoosh sound, which is what I did. There were 15 CCs [sic] in the normal balloon that was in prior, and when you put in the new balloon, I only put in l0 CCs [sic] due to concerns of his bladder being full already.-What specific time did you give the medication to the resident? RN6 answered by indicating that she gave the medication right before taking the 15-minute break. She stated she was not positive, but her best guess was 9:15 AM. RN6 explained that she pulled it from the med cart and narcotics box, then immediately gave it to the resident. RN6 further explained that she also attempted other techniques, such as a warm blanket and breathing techniques, to calm the resident. She further expressed that CNA12 and CNA14 witnessed her physically put the pain pill in his mouth.Continued review of the facility's investigation, dated 10/25/24 through 11/01/24, provided by the facility, included a statement from the facility's medical director regarding his professional opinion on auscultation of a bladder using a stethoscope to check the placement of the Foley catheter. The medical director stated you would not be able to determine the placement of a Foley catheter using a stethoscope, as was indicated by RN6. The medical director stated that some nurses and providers used a stethoscope to determine the placement of a G-tube, but never for a Foley catheter. During a telephone interview on 07/30/25 at 4:03 PM, RN6 stated that she arrived at work on 10/25/25 at 6:00 AM, attended a mandatory meeting at 6:30 AM, and was running a little behind due to the meeting. RN6 stated at approximately 7:15 AM, staff notified her that R4 was having a lot of pain. RN6 stated that this was her first day back after four consecutive days off. So, she went to look through some of his paperwork. She stated that apparently, R4 had been complaining of abdominal pain and the inability to urinate for a couple of days, and that none of the nurses really did anything about it. She stated that when she went into the resident's room, the resident complained of 10 out of 10 pain, his abdomen was completely distended, and he did not have any urinary output, noting that there was less than 50cc in his catheter drainage bag and that R4 complained of abdominal pain. -RN6 stated that she completed a full assessment on R4 and tried to see what she could do to relive his pain because he had not urinated from what she concluded from the documentation for greater than 24 hours. RN6 stated that she first tried to flush R4's catheter with 100cc of normal saline to see if it was blocked, adding that when you get a UTI, especially one that's been brewing for a while, the urine gets real thick and kind of like snot, it's nasty. She stated that her attempt to flush the catheter was unsuccessful. So, she removed the catheter and replaced it with a new one to see if she could get urine and gave him some pain medication and then went to look for the bladder scanner so that she could report to the EMT how much urine he retained in his bladder and that if the new catheter had not drained or started to drain, she knew that she was going to send him to the hospital. She stated she interrupted the clinical meeting, looking for the bladder scanner, and stopped to go to the bathroom, since she had been in with R4 for over an hour and a half. -RN6 stated that upon returning to the floor, she found two nurses (RN3 and LPN4) present. RN6 stated one of them was on the phone with 911, and they had not been with this resident all morning, unlike her. She stated so, she asked RN3 if she had obtained a doctor's order because she had not called the doctor yet. RN6 stated she was in the process of gathering the last piece of information (i.e., results of the bladder scanner) and then calling the doctor. She stated reportedly, RN3 said, I don't give a F*** and assisted the paramedics and staff get R4 out the door, but RN3 never asked me once what I did previously for the resident. -When asked how she knew that the new indwelling catheter that she inserted was in place prior to inflating the balloon, RN6 stated that she did not inflate the balloon after inserting the catheter [contrary to her verbal statement, dated 10/28/24], which she believed was the source of confusion. She stated her initial attempt to flush the existing catheter with saline was unsuccessful, indicating a blockage. She stated upon placing a new catheter, she assessed the patient's condition through bowel and bladder sounds, noting signs of fluid retention (tympany).RN6 stated without access to a bladder scanner to confirm, she opted to leave the catheter in place, administer pain medication, and create a calming environment to help the patient relax and vasodilate to allow urine to flow naturally.-When asked if she took a break or left the facility after seeking the bladder scanner, RN6 explained that she informed her team she would be gone for 10-15 minutes to locate the scanner, as her earlier text to the Director of Nursing had gone unanswered. She stated during that time, she briefly used the restroom, stepped outside the back door for a few deep breaths, and looked up the Emergency Medical Services (EMS) contact number on her phone, intending to call them instead of 911, which typically required a doctor's order. She emphasized that she did not leave the facility and returned to the floor within 16 minutes. She stated that she was gathering final assessment details to support a medical decision, noting that the patient was later found to have over 3000cc of retained urine [contrary to the ED Encounter Note, dated 10/25/24] and a severe UTI, explaining the intense pain he was experiencing.During an interview on 07/30/25 at 2:12 PM, RN3 stated that RN6 came into the morning meeting (time unknown), telling us that she might be sending R4 out to the hospital because he had not had urine output in the last 24 hours. RN3 stated shortly after that, approximately 10 minutes later, the clinical meeting finished. As she and LPN4 approached the first two nurses' stations, she stated she could hear R4 screaming. She stated that she went to the resident's room, saw another CNA entering R4's room. RN3 stated so, she asked the CNA where R4's nurse was, and the CNA said that she went on break. RN3 stated so, she went to assess R4 and told the CNA to get the vital sign machine and meet her in R4's room. When she went into R4's room and assessed his vital signs, she stated she tried to check the resident's catheter because he had no urine drainage. When she went to palpate the shaft of his penis, RN3 stated he told her to stop because it was too painful. She stated that she asked if she could remove the catheter and put in a new one, and R4 said, No, don't touch me. RN6 then advised R4 that if he did not want her to touch him, she would need to send him to the hospital, and he said OK. -RN3 stated that she completed a full head-to-toe assessment of R4 to see if there was something else that could be causing the pain. She stated upon assessment, the resident had tympany noted in his right upper quadrant. RN3 stated after that, she left the room. She stated she told him that she would be right back, that she was going to call the resident's son and physician. She stated that she informed the resident's son about his change in status. RN3 stated that the resident's son was ok with sending R4 to the hospital if that was what the doctor wanted. RN3 stated that she spoke to the doctor, who was ok with sending R4 to the hospital, and that she called 911. -RN3 stated about that time, RN6 came back from break and asked her what they were doing. She told her that she heard R4 screaming in the hall and that he would not let her do anything with his catheter. She stated that she asked RN6 what she did, and that RN6 stated that she medicated him with his normal pain meds and was waiting for vagal response. RN3 stated that RN6 said that she replaced the catheter because the other one was not draining, and that the one she placed was also not draining. RN6 said that she listened to R4's stomach and heard the same thing RN3 did. She stated she and RN6 went back into R4's room, waiting for Emergency Medical Services (EMS) and the fire department to arrive. RN3 stated RN6 gave report to EMS and the fire department, then RN3 gave her report. She stated RN6 left the room, but she stayed with him because he was still in pain, and she tried to calm him down. RN3 added that she was not sure if she called the doctor first or 911 because R4 was in so much pain. But the doctor and son were both ok with sending him to the hospital.During a telephone interview on 07/30/25 at 3:15 PM, CNA14 stated that on 10/25/24, R4 was in significant pain and RN6 was trying to determine the cause. CNA14 expressed that she had already provided her statement in court and was unsure what more she could add. During the call, the interviewer verbally reviewed CNA14's witness statement, which had been obtained by the facility on 10/28/24, at approximately 2:28 PM. The statement described CNA14 as being present with RN6 and CNA12, attempting to calm R4, who was visibly in pain, screaming, and appearing unable to get comfortable. It also stated that RN6 removed and replaced R4's catheter, but he remained unable to urinate. According to the statement, RN6 suspected the inability to urinate was due to R4 being tense from pain. The statement further noted that RN3 entered the room shortly after and asked CNA14 to take R4's vitals before they sent him to the hospital. During the review, CNA14 interrupted to clarify that RN3 did not enter the room at that time, but approximately 20 minutes later. The remainder of the statement was reviewed, which indicated that CNA14 cared for multiple residents and was in and out of R4's room. However, CNA14 denied being in and out of the room, stating that R4 was sent to the hospital. When asked if she had anything further to add, CNA14 stated that RN6 did everything she should have done to care for the resident. When asked whether RN6 went on break during that time, CNA14 responded that RN6 had gone to look for a bladder scanner but was unsure if she had taken a break. CNA14 also expressed confusion about the origin of the verbal statement.During a telephone interview on 07/30/25 at 3:35 PM, the PDON stated that on 10/25/24, RN6 came into the conference room during the clinical meeting and said that she felt that she needed to send R4 out because he did not have any urine output in the last 24 hours. PDON stated RN6 then asked about the facility's Doppler (bladder scanner), which was broken, and that the facility needed to reorder one, and that it was ok to send R4 out [to the ER]. She stated at that time, the staff asked RN6 if she needed help, and RN6 said, No, I've got this. PDON stated after the meeting, RN3 and LPN4 went to the floor and reported hearing R4 screaming in pain, and they went to check it out. She stated RN6 was nowhere to be found. PDON stated that when RN6 came back to the unit, RN6 said that she was waiting for the pain medication to take effect. She stated later they found out that RN6 inflated the balloon of the catheter in R4's urethra. She stated R4 went out to the hospital and came back the same day. PDON stated both nurses (RN3 and LPN4) felt strongly that RN6 should not have left R4 in that condition. She stated so, they took all necessary steps because we considered her actions to be neglectful. She stated RN6 went to the Administrator's office, provided a statement, and went home pending an investigation. The PDON stated that when R6 returned, the ER report indicated the catheter was placed incorrectly. The PDON stated there was no reason RN6 should have waited for the pain medication to take effect because she had given him the pain medication an hour prior. When asked if RN6 went on break after leaving the conference room, the PDON stated that a review of the surveillance video showed RN6 left the building for approximately 15 to 20 minutes, but she could not say where she went or when she left the building. During an interview on 07/30/25 at 4:45 PM, the Activity Director (AD) stated that on 10/25/24, RN6 came into the morning stand-up (clinical meeting) to provide an update about R4. The AD stated RN6 stated that she was going to send him out to the ER due to not urinating. The AD stated that it sounded like RN6 wanted to use the bladder scanner as an intervention, but they did not have access to it, or it was broken at the time. She stated so, they wanted to send R4 to the ER. The AD stated that she saw RN6 come back through the double doors across from her office and next to the bistro, but she was not sure what time this was or where she was coming from, stating that she just did not see her walk back toward the floor [where R4 resided]. During a telephone interview on 07/31/25 at 8:16 PM, CNA12 stated that on 10/25/24, she was training CNA14 and working with R4 alongside CNA13. CNA12 stated R4 had pressed his call light due to a bowel movement. CNA12 stated when CNA12 and CNA14 responded, they noticed R4 was scheduled for a shower. CNA12 explained that R4 preferred bed baths due to his pain, which often caused him to scream-a behavior familiar to the CNAs. She stated while assisting R4, CNA12 observed that he was in more pain than usual and asked if he wanted her to stop the bed bath. She stated CNA14 helped R4 with breathing techniques to manage his pain, which had reportedly started the day before. CNA12 stated RN6 entered the room in response to R4's screaming and labored breathing. CNA12 reported R4's condition to RN6, who began assessing him. She stated the night CNA had mentioned R4 was feeling better than the previous day, although he had minimal urinary output overnight. CNA12 stated that RN6 assessed R4's lower right abdominal pain and checked his bowels, stomach, and bladder for signs of urinary retention. CNA12 stated RN6 asked about R4's urine output, and CNA12 reported approximately 200cc, which was lower than usual. She stated R4 mentioned he had experienced pain the day before. She stated RN6 suspected urinary retention and expressed concern about the lack of a working bladder scanner. CNA12 stated RN6 eventually changed R4's catheter, but no urine was obtained. CNA12 noted that R4 was extremely sensitive to touch and screamed during the procedure. She stated RN6 administered a pain pill and asked R4 if it was dissolving, though CNA12 was unsure when RN6 brought the medication into the room. She stated RN6 stated she would speak to management about the bladder scanner. CNA12 recalled speaking with RN6 and CNA14 after leaving R4's room and asking if they had known about R4's ongoing issues. She stated RN6 responded that the previous nurse had not informed her. CNA12 was unsure whether RN6 took a break but remembered RN6 saying she was stepping out to inquire about the bladder scanner. CNA12 stated she later saw RN6 and LPN4 in R4's room again, approximately 10 to 30 minutes after they had left. CNA12 stated she did not know whether RN6 inflated the catheter balloon but assumed she did, as it appeared consistent with standard nursing practice.During a telephone interview on 08/01/25 at 1:39 PM, CNA13 stated R4 had issues with his catheter the day before (10/24/24) and that RN9 flushed his catheter and was able to get urine output. CNA13 stated so, when CNA15 came to work, she told her to keep an eye on R4 because of these issues. The next day, CNA13 stated she asked CNA15 how R4 was doing, and CNA15 said he was not doing well and that he had only had 200cc output that day. CNA13 stated that she asked CNA15 if she told[TRUNCATED]