Failure to Ensure Appropriate Suprapubic Catheter Care After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to a long-term resident with a suprapubic catheter (SPC) following hospitalization. The resident, who had a history of quadriplegia, traumatic brain injury, neurogenic bladder, and recurrent urinary tract infections (UTIs), was readmitted to the facility after a hospital stay for sepsis and catheter-related UTI. Upon readmission, there were no physician orders in place for changing the suprapubic catheter, despite previous orders for monthly changes and daily flushes, and despite the resident’s complex urological history and recent hospital discharge instructions. Medical record review showed that prior to hospitalization, the resident’s SPC was changed monthly at the facility, and during the hospital stay, the catheter was changed twice. However, after the resident returned to the facility, the previous order for monthly catheter changes was not reinstated, and no new orders were obtained for catheter changes or daily flushes. Interviews with nursing staff and the unit manager revealed that they were aware of the need for regular catheter care but did not ensure that appropriate orders were in place. The resident’s sister reported that she had communicated the hospital discharge instructions regarding daily flushes and monthly changes to facility staff, but these instructions were not documented or acted upon. Further review of the resident’s orders and care plan indicated that only general monitoring and as-needed irrigation were ordered, with no specific instructions for routine catheter changes or daily flushes. Progress notes did not show any evidence of staff contacting the urologist or primary care provider to clarify the care needed for the SPC. The facility’s policy required documentation of all catheter care, but there was no evidence that the necessary care was provided or documented after the resident’s readmission, resulting in a failure to meet the standard of care for residents with indwelling catheters.