Failure to Maintain and Monitor Suprapubic Catheter Care and Documentation
Penalty
Summary
The facility failed to maintain and monitor a resident's urinary catheter system, specifically for a resident with a suprapubic catheter. The resident, who was admitted with multiple diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and a history of urinary tract infection, was dependent on staff for all activities of daily living and had a care plan that addressed some aspects of catheter care. However, the care plan did not include interventions to monitor the suprapubic stoma or to record the amount of urine collected in the catheter drainage bag. Physician orders required daily cleansing of the suprapubic catheter site and application of a dry dressing, but there was no documentation that this was performed on several specified dates. Additionally, there was a lack of assessment of the catheter stoma site in the medical record. Observation revealed that the resident did not have a dressing in place at the suprapubic insertion site as ordered. Electronic documentation also showed inconsistent recording of urinary output, with several shifts and days lacking any documentation of output. The facility's catheter care policy required catheter care every shift, regular changing of privacy bags, and emptying of drainage bags at specified intervals, but these practices were not consistently documented or observed. The Director of Nursing confirmed the lack of documentation regarding the catheter stoma condition, site treatment, and urinary output.