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F0690
D

Failure to Provide Monthly Suprapubic Catheter Changes as Ordered

Roseville, Minnesota Survey Completed on 05-21-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with moderately impaired cognition and diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and kidney calculus was identified as having a suprapubic catheter. The resident's care plan specified interventions such as regular toileting assistance, pericare, monitoring for urinary tract infection (UTI) symptoms, and changing the suprapubic catheter according to policy. Physician orders directed that the catheter be changed monthly and as needed. However, review of the resident's Medical Administration Record (MAR), Treatment Administration Record (TAR), and progress notes from November 2024 through April 2025 showed no documentation that the catheter had been changed since admission. Interviews with nursing staff, including a registered nurse, a nurse manager, and the director of nursing, confirmed that the physician's orders for monthly catheter changes were not followed, and there was no evidence of catheter changes in the records. Additionally, a nurse from the urology provider confirmed the necessity of monthly catheter changes to prevent complications. The facility's catheter care policy did not specify the required frequency for catheter changes, contributing to the lack of compliance with physician orders.

See complete original report
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