Deficient Suprapubic Catheter Site Care and Infection Control
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter did not receive appropriate catheter site care due to the facility's lack of a specific policy guiding daily suprapubic catheter site care. During an observation, a registered nurse performed suprapubic catheter care but failed to change gloves or perform hand hygiene after removing the old dressing and before applying a new dressing. This lapse in infection control practice was directly observed and acknowledged by both the nurse and the assistant director of nursing when questioned. The facility's existing policy on suprapubic catheterization did not address hand hygiene between glove changes during site care, and a new policy created during the survey still omitted this critical step. The resident involved had multiple sclerosis, neuromuscular dysfunction of the bladder, and an appendicovesicostomy, and was cognitively intact. The resident had previously experienced a urinary tract infection with sepsis. The lack of a clear policy and failure to follow proper infection control procedures during catheter care were directly linked to the deficiency cited by surveyors.