Failure to Provide Timely Assessment and Intervention After Suprapubic Catheter Dislodgement
Penalty
Summary
The facility failed to provide appropriate assessment and timely intervention for a resident after a fall resulted in the accidental removal of a suprapubic urinary catheter. The resident, who had diagnoses including diabetes mellitus, chronic kidney disease, and urinary retention, was dependent on staff for transfers and personal care. After the fall, staff observed that the suprapubic catheter was missing and reported this to the nurse on duty. However, there was no immediate assessment or intervention for the catheter removal, and the care plan did not provide guidance for staff in the event of catheter dislodgement. Multiple staff interviews revealed that the catheter was noted to be missing around 2:30 PM, but the resident did not receive an appropriate nursing assessment or intervention for approximately seven hours. The oncoming nurse was not informed of the catheter removal during shift change, and only after being notified by CNAs did the nurse assess the resident and contact the physician. Emergency Medical Technicians were called, but the resident initially refused transport to the hospital. The resident later agreed to be transported, but by that time, the suprapubic stoma had closed, and a replacement catheter could not be inserted. Clinical documentation and interviews confirmed that the resident experienced prolonged leakage of urine from the abdominal opening, was confined to bed for several hours, and did not receive timely care for the catheter issue. The Emergency Department was unable to replace the suprapubic catheter due to the delay, and a Foley catheter was placed instead. The facility's care plan lacked specific instructions for staff in the event of suprapubic catheter dislodgement, contributing to the delay in appropriate care.