Deficient Suprapubic Catheter Care and Documentation
Penalty
Summary
Licensed nurses at the facility failed to demonstrate competency in assessing and changing a suprapubic catheter for a resident with a neuromuscular bladder dysfunction. The resident was admitted with a suprapubic catheter, and physician orders specified that the catheter should be changed as needed for dislodgement, malfunction, or leakage. However, there was no written documentation of any catheter changes over a four-month period, despite a nurse recalling a change due to leakage two months prior. The Director of Nursing was unable to provide evidence of the procedure or documentation, and the Director of Staff Development could not produce records of nurse competencies related to suprapubic catheter care and changes. Additionally, the facility's policy and procedure for suprapubic catheter care did not specify which clinical personnel were qualified to change the catheter, nor did it outline the required qualifications or competencies for performing this task. The policy also failed to align with current standards set by the Society of Urologic Nurses and Associates, which require clear protocols regarding personnel qualifications and training for suprapubic catheter changes. These deficiencies were identified through interviews, record reviews, and policy examination.