Failure to Monitor and Treat Suprapubic Catheter Site
Penalty
Summary
The facility failed to ensure ongoing monitoring and assessment of a resident with a suprapubic catheter, resulting in unaddressed drainage and skin impairment at the stoma site. During observation, the resident was found with a disposable brief soaked in serosanguineous drainage, no dressing on the suprapubic catheter site, and visible redness and irritation of the surrounding skin. The catheter was not secured to the abdomen as required. The resident reported that dressings were usually applied twice daily, but none was present after a recent shower. The assigned CNA was unaware of the missing dressing and had not yet provided morning care. Nursing staff, including an agency nurse and wound care nurse, were not informed of the absence of the dressing or the condition of the site until prompted by the surveyor. Documentation in the medical record did not accurately reflect the observed condition, as the wound care nurse documented intact skin with no redness or drainage, contrary to what was seen during the survey. The nurse also took a photo of the site using a personal cell phone, which was acknowledged as a violation of resident privacy. The nurse did not contact the physician for new treatment orders, instead applying a barrier cream not ordered for the suprapubic site. Facility policy required daily and as-needed dressing changes for suprapubic stoma sites with drainage, monitoring for redness or maceration, and securing the catheter to the abdomen. Policies also mandated prompt identification, documentation, and physician notification for skin breakdown. These protocols were not followed, as evidenced by the lack of dressing, improper documentation, failure to secure the catheter, and absence of physician notification for the observed drainage and skin impairment.