Failure to Accurately Document and Perform Suprapubic Catheter Changes
Penalty
Summary
The facility failed to ensure the accuracy of resident records and documentation for a resident with an indwelling suprapubic catheter. The resident, who had multiple diagnoses including neuromuscular bladder dysfunction and was dependent on staff for activities of daily living, had physician orders for monthly suprapubic catheter changes. Documentation in the treatment administration records indicated that the catheter was changed as ordered each month by various LPNs. However, interviews with the LPNs revealed that none of them had actually performed the catheter change, and some believed the documentation referred only to changing the catheter bag, not the catheter itself. One LPN stated they had no training on how to perform the procedure and were unaware of any such order. Further review showed that the resident's physician was not notified that the catheter changes were not being performed as ordered. The Director of Nursing confirmed that the catheter exchange was documented as completed when it had not been done. The deficiency was identified through record review, staff interviews, and communication with the resident's power of attorney, who also confirmed through messages with staff that the catheter had not been changed as required.