Failure to Ensure Timely Suprapubic Catheter Changes
Penalty
Summary
The facility failed to ensure timely changing of a suprapubic (SP) urinary catheter for one resident. Observations revealed that the resident's catheter tubing appeared faded, soiled, and had areas of black discoloration, with the drainage tube clouded with sediment. Interviews with staff indicated uncertainty about when the last catheter change occurred, and the resident was unsure of their last urology visit or catheter change. Record review showed the last documented urology appointment was several months prior, with physician instructions for the SP catheter to be changed every six weeks. However, there was no documentation in the facility records of any recent catheter changes, and staff were unable to provide evidence of compliance with the prescribed change schedule. The resident had a history of heart failure, chronic kidney disease, and high blood pressure, and had been readmitted to the facility multiple times. The medical record included inconsistent or outdated orders regarding catheter type and size, and lacked clear documentation of catheter change timing. Despite requests, the Director of Nursing was unable to provide documentation of catheter changes prior to the survey exit. The facility's policy required clarification orders to initiate treatment according to the plan of care, but this was not followed in the case of the resident's catheter care.