Failure to Provide Proper Suprapubic Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care and treatment for residents with suprapubic catheters, as evidenced by the lack of adherence to physician and specialist recommendations for catheter flushing and routine catheter changes. For one resident with a history of benign prostatic hyperplasia and urinary retention, medical records showed that urology and pelvic medicine specialists repeatedly recommended flushing the suprapubic catheter twice daily and exchanging the catheter every 4-6 weeks. However, documentation revealed significant lapses, including no record of catheter changes for several months and a prolonged period without ordered or documented flushes following a hospitalization. The care plan also indicated a need for monthly catheter changes, but there was no evidence these were performed as required. Interviews with the DON confirmed that there was no documentation of catheter flushes or changes during the specified periods, and that communication issues with multiple consulting providers contributed to the lack of consistent care. The DON acknowledged that catheter changes were expected to be performed by facility staff unless otherwise specified by the consulting provider, but could not provide records to support that these tasks were completed. The consulting provider also clarified that unless specifically documented, catheter changes were not performed by their team and were the responsibility of the facility per the resident's care plan. A second resident with a history of obstructive and reflux uropathy and overactive bladder also did not receive routine suprapubic catheter changes as ordered. The resident's medical record showed an order for catheter changes every four weeks, but this was discontinued and changed to 'as needed,' with no documentation of changes for several months. Urology consultation notes continued to recommend routine exchanges every 4-6 weeks, but there was no evidence these were carried out. Staff communication with the resident's representative incorrectly indicated that monthly changes were being performed by urology staff, despite a lack of supporting documentation.