Delayed Catheter Care Resulting in Resident Discomfort and Pain
Penalty
Summary
A deficiency occurred when a resident with paraplegia, major depressive disorder, and ankylosing spondylitis did not receive scheduled in-and-out catheter care for approximately 2.5 hours past the ordered time. The resident was care planned for self-catheterization, but facility staff were responsible for performing the procedure as the resident was unable or unwilling to do it independently. Medical orders specified catheterization every six hours, but on the day in question, there was no documentation of the 4:00 pm catheterization, and the next recorded care was at 10:00 pm, with staff interviews confirming the procedure was actually performed around 6:30 pm. The resident reported significant discomfort and pain due to the delay, stating he requested catheter care multiple times without timely response. He described being in 'massive pain' and required a pain pill for relief. Staff interviews corroborated that the resident expressed discomfort and that the delay in catheter care was due to staff attending to other residents in pain. The ADON acknowledged being informed of the resident's request but was occupied with other urgent care needs, and there was a lack of communication and delegation to ensure the resident's catheter care was completed as ordered. Documentation was inconsistent, with the LPN who performed the catheterization not recording the actual time of care, instead documenting it at the next scheduled time. Multiple staff members, including the DON and RNs, recognized that orders should be followed and that delays could result in resident discomfort and pain. The facility's policy emphasized prompt response to resident requests for toileting assistance to promote dignity and quality of life, which was not adhered to in this instance.