Delay in Suprapubic Catheter Care Resulting in Resident Discomfort
Penalty
Summary
The facility failed to provide timely care and services for a resident with a suprapubic catheter, as required by physician orders and the resident's care plan. The resident, who had quadriplegia and neurogenic bladder, was dependent on staff for all activities of daily living and required her suprapubic catheter to be lavaged with 200 cc every Monday, Wednesday, and Friday during the day shift. On the day in question, the resident began requesting the catheter flush at 10:00 a.m., but the procedure was not performed by 3:20 p.m. despite multiple requests. The resident reported increasing abdominal spasms and discomfort due to the delay. Staff interviews revealed that the treatment nurse was absent, and coverage was uncertain. The registered nurse acknowledged being too busy with other admissions and discharges to perform the catheter flush as scheduled. The facility's policy required that residents receive care and services to maintain or improve their ability to carry out activities of daily living, but this was not followed in this instance, resulting in the resident experiencing discomfort and bladder spasms.