Failure to Provide Proper Suprapubic Catheter Care and Maintenance
Penalty
Summary
Staff failed to provide proper suprapubic catheter care and maintenance for a resident, resulting in an unidentified and untreated skin breakdown around the catheter insertion site. The resident reported that catheter care was inconsistently performed, with cleaning occurring only about every other brief change, and that staff often used alcohol wipes instead of the facility-approved cleanser or mild soap and water. The resident also noted frequent bladder infections, leakage, and that the catheter was not consistently secured to prevent pulling, which contributed to skin redness and maceration. During observations, staff were seen using alcohol wipes to clean the catheter and insertion site, and the catheter was not secured afterward. Redness and maceration the size of a nickel were observed around the insertion site, and the resident stated this condition was ongoing and worsened when the catheter was not secured. Interviews with staff revealed a lack of clarity regarding the specific cleaning procedures and products to use for suprapubic catheter care, with some staff unaware of the resident's care orders or the presence of skin breakdown. Documentation in the care plan and facility policy indicated that staff should inspect the insertion site for signs of infection, use approved cleansers, and secure the catheter to prevent pulling. However, these procedures were not consistently followed, and communication lapses were evident, as some nurses were not informed of the skin breakdown. The failure to adhere to established catheter care protocols and to report and address skin issues led to the deficiency.