Failure to Follow Physician Orders for Suprapubic Catheter Care
Penalty
Summary
Facility staff failed to provide care consistent with professional standards for a resident with a suprapubic catheter (SPC). The resident, admitted with diagnoses including bladder-neck obstruction, obstructive and reflux uropathy, infection and inflammation due to an indwelling catheter, and urinary retention, had a care plan specifying that catheter irrigation should only occur with a physician's order. However, review of the clinical record revealed multiple instances where nursing staff irrigated the resident's SPC without a physician's order, as documented in several nursing notes. The physician's orders did not include instructions for irrigation, only for catheter changes as needed for occlusion or leakage. Interviews with the unit manager confirmed that staff had been instructed not to irrigate catheters without a physician's order, and that the resident did not have such an order. The unit manager acknowledged that the SPC should not have been irrigated and that this practice had been an issue in the facility previously. The resident was observed to have a urinary drainage collection bag in place and reported some issues with the catheter, though was unable to provide specifics. The failure to follow the care plan and physician's orders regarding SPC irrigation constituted a deficiency in care.