F0690

D

Failure to Schedule Ordered Urology Follow-Up for Resident With Suprapubic Catheter

Salisbury, North Carolina Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to schedule a urology follow‑up appointment as ordered for a resident with a suprapubic catheter and active urinary issues. The resident had been hospitalized for bilateral hydronephrosis with ureteral stents and had a suprapubic catheter placed, with hospital urology documentation indicating the need for stent changes in 4–6 months and upsizing the suprapubic catheter from 14 French to 16 French. After admission, the resident’s care plan identified risk for UTIs related to the suprapubic catheter and urinary obstruction, and a subsequent radiology note documented successful upsizing of the suprapubic catheter. The resident was cognitively intact and admitted with an indwelling (suprapubic) catheter.

Following the upsizing procedure, the NP documented ongoing problems, including leakage around the suprapubic site and from the penis, and purulent drainage at the catheter site. On a later visit, the NP assessed infection and inflammatory reaction due to the suprapubic catheter, started clindamycin, and wrote a physician order for a urology consultation to be scheduled as soon as possible. The order was transcribed and signed by a nurse, and the resident received the prescribed antibiotic as confirmed by MAR review and staff interview. However, record review from the date of the order through the survey date showed no documentation that a urology consultation was ever scheduled.

Interviews revealed multiple communication and process failures that contributed to the missed appointment. The scheduler stated she was unaware of the urology consult order and had not received it from nursing, and she did not recall any discussion with the NP about the appointment. The NP reported she had spoken directly with the scheduler and assumed the appointment had been made, and later expressed concern that the resident had not had a urology follow‑up. A NA reported frequent leakage requiring incontinent care but did not report these concerns to the charge nurse, believing staff were already aware. The urology clinic nurse confirmed the resident had not been seen in the office and stated a follow‑up visit should have been scheduled within 30 days after the suprapubic catheter upsizing and was still needed as soon as possible. The DON and Administrator both stated their expectation that physician orders, including the urology follow‑up, should have been carried out, and the Medical Director stated the appointment should have been escalated due to the leaking and infected suprapubic catheter area.