The resident was supposed to receive intermittent catheter care at 3:30 pm. He didn't get it until approximately 6 pm.
Staff at The Center at Parmer told inspectors they were dealing with other emergencies that day, including residents who were coding and others experiencing pain. The Assistant Director of Nursing was addressing pain complaints from two other residents when the catheter care was due.
The Executive Director said his staff would normally have provided the resident's catheter care on schedule, but "if a resident was coding that resident would be the priority." He acknowledged that staff was "addressing the most emergent situation, residents who were in pain."
The resident told administrators he felt his stomach was very full and "felt a little better" after finally receiving the catheter care around 6 pm.
But the documentation didn't match what actually happened. Licensed Practical Nurse A recorded the catheter care as occurring at 10 pm, not 6 pm, and failed to note it as a late entry for the actual time of care.
When inspectors interviewed nursing staff about the delay, they got conflicting assessments of the harm.
The Director of Nursing, who started working at the facility after September 2, said she didn't think the resident would have been uncomfortable receiving catheter care 2.5 hours late. She called 1,500 milliliters "an average amount of urine output" and said if the resident reported discomfort, "it could describe a large range of what was uncomfortable."
She couldn't answer what negative effects might result from delayed catheter care because "there were too many possibilities." When she later visited the resident to ask about his experience, he told her "everyone had been great and he had no issues and no problems."
But two experienced registered nurses painted a different picture of what the delay meant for the resident.
RN E, who had "done a lot of resident catheter care," said staff typically have an hour before and after the ordered time to provide the care. A 2.5-hour delay could definitely make a resident "uncomfortable and verbalize that he was uncomfortable."
She explained that 1,500 milliliters "might be a lot" depending on the resident's medications and fluid intake. The possible negative effects of delayed catheterization included discomfort, pain, and distention - "enlargement or swelling of a hollow organ or structure due to increased pressure or fluid accumulation." The resident "could be upset or angry."
RN C, who also had extensive catheter care experience, was more direct about the consequences. "If a resident did not receive catheter care according to the order it could be a problem, and multiple things could happen with the resident," she said. "The resident might be in pain and might be frustrated."
Both nurses agreed that orders should be followed, and if staff couldn't follow them, they needed to get help or find someone to follow up.
RN E said it was "the ultimate responsibility of the nurse taking the hall that day to make sure that this was taken care of." RN C said "it was the responsibility of the resident's nurse to have made sure catheter care was done."
Interestingly, RN C noted that while 1,500 milliliters was "a lot of urine output," when compared to this particular resident's average output, "it looked normal."
The facility's own dignity policy, dated April 2, 2024, requires that "each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality." Staff are specifically directed to "promote dignity and assist residents as needed by promptly responding to the resident's request for toileting assistance."
The inspection found this represented minimal harm or potential for actual harm affecting few residents. But for the resident who spent hours with an uncomfortably full bladder, waiting for care that should have been routine, the impact was immediate and personal.
The disconnect between what happened and what was documented raises questions about both the quality of care and the accuracy of medical records at the facility. While emergencies do occur in nursing homes, the failure to properly reschedule or delegate routine care left a vulnerable resident suffering unnecessarily.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Center At Parmer from 2025-11-24 including all violations, facility responses, and corrective action plans.