Failure to Report and Investigate Catheter-Related Hospitalization
Penalty
Summary
The facility failed to report and investigate an incident of potential neglect involving a resident who was hospitalized due to a preventable complication related to a suprapubic catheter. The resident, who was cognitively intact and required minimal assistance with activities of daily living, had a history of obstructive uropathy and an indwelling urethral catheter, which was later replaced with a suprapubic catheter. Hospital documentation revealed that the resident was admitted with an obstructed suprapubic catheter, calcifications at the insertion site, a hardened catheter balloon, and cellulitis caused by leaking urine. The resident required surgical and intravenous interventions for these complications. Facility records indicated that the suprapubic catheter had not been changed since 11/12/2024, despite clinical orders specifying monthly changes. When questioned, the Director of Nursing (DNS) acknowledged that no investigation had been completed regarding the hospitalization, and was unaware of the hospital's request for documentation about the last catheter change. Communication between staff members regarding the records request was not effectively addressed, and the administrator confirmed that the incident should have been investigated and reported to the appropriate agencies.