Failure to Consistently Provide Suprapubic Catheter Care per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter did not consistently receive care and treatment in accordance with professional standards of practice, facility policy and procedure, and physician's orders. The resident, who had multiple diagnoses including multiple sclerosis, malnutrition, neuromuscular dysfunction of the bladder, depression, and anxiety disorder, was cognitively intact and able to report her care. She stated that staff would miss days of catheter care and treatment. Review of the resident's care plan and physician's orders showed that the suprapubic catheter was to be flushed with 60 cc saline every shift to prevent sedimentation and clogging, and the insertion site was to be cleansed every evening shift. However, treatment administration records revealed multiple missed shifts for both catheter flushing and site cleansing across several months. These omissions were confirmed by the nurse supervisor, who acknowledged that the care and treatment were not done consistently as ordered. Interviews with facility staff, including the nurse supervisor, director of staff development, and DON, confirmed that the expected standard was to follow the physician's orders for catheter care and treatment. The facility's policies also required that care be provided in accordance with physician orders and professional standards. The lack of consistent documentation and performance of the required catheter care constituted the deficiency.
Plan Of Correction
Bowel/Bladder Incontinence, Catheter, UTI How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #346 suprapubic catheter care was completed on 04/09/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) Audit of current residents with catheters was completed on 04/11/2025 by Medical Records Director to ensure that residents had their catheter care completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents' catheter care is done consistently. d) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. The plan of correction is integrated into the quality assurance system. The facility will identify other residents having the potential to be affected by the same deficient practice and take action: b) Audit of current residents with catheters was completed on 04/11/2025 by Medical Records Director to ensure that residents had their catheter care completed consistently. All residents have the potential to be affected by this deficient practice. No other residents were affected by the deficient practice. Measures to prevent recurrence: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all residents' catheter care is done consistently. d) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. Monitoring and evaluation: e) DON and/or designee will review treatment administration records to ensure catheter care is being completed. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation, and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. Date of review: 04/17/2025