Failure to Maintain Dignity and Proper Technique During Suprapubic Catheter Care
Penalty
Summary
During routine suprapubic catheter care for a resident with a history of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome, and prior cerebrovascular events, staff failed to follow proper technique and maintain the resident's dignity. The care plan and physician orders required cleansing the suprapubic site every shift with soap and water, covering with split gauze, and maintaining infection control practices. However, observation revealed that the resident was left fully exposed throughout the procedure, with the brief around the knees, and was not covered to maintain dignity. The resident was positioned flat in a Trendelenburg position, and the catheter care was performed by a CNA, assisted by the ADON and an RN. During the procedure, the CNA cleansed the catheter insertion site using a washcloth dipped in soapy water, holding the catheter approximately three inches below the insertion point, which caused tension on the catheter tubing. The same process was repeated with rinse water. Interviews with the ADON, CNA, and RN confirmed that the catheter was not properly secured at the insertion point, resulting in tugging on the tubing, and that the resident should have been kept covered except during the actual peri-care. The staff acknowledged that proper technique and dignity were not maintained during the catheter care.