Failure to Maintain Complete Medical Records for Suprapubic Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents with suprapubic catheters (SPC). For one resident with a history of benign prostatic hyperplasia and urinary retention, the facility was unable to provide medical health information to the hospital emergency room staff upon transfer. Review of the resident's records showed inconsistent documentation of SPC changes, with the last recorded change in December, and no documentation of changes from January through May, despite care plan and urology consult recommendations for routine exchanges every 4-6 weeks. The Director of Nursing (DON) confirmed that there was no documentation available to support that the SPC was changed during this period and indicated that different urology providers had varying communication methods, which contributed to the lack of documentation. For another resident with obstructive and reflux uropathy and an overactive bladder, the facility's records also lacked documentation of SPC changes as ordered. The resident had an order for SPC changes every four weeks, which was later changed to 'as needed.' However, there was no documentation in the Treatment Administration Records (TARs) of any SPC changes from January through July, despite ongoing urology consult notes recommending routine exchanges every 4-6 weeks. The DON was unable to provide documentation to confirm that the SPC was changed as recommended during this time frame. Interviews with facility staff and urology consultants revealed that while providers may have performed SPC changes during consultation visits, these were not consistently documented in the residents' medical records. The lack of documentation meant that the facility could not demonstrate compliance with physician orders or care plan interventions regarding SPC management for the affected residents.