F0690

D

Failure to Arrange Timely Transportation for Suprapubic Catheter Placement

Watertown, Wisconsin Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to ensure timely placement of a suprapubic catheter for one resident when transportation was not secured for a scheduled medical appointment. The resident had multiple diagnoses including complete paraplegia, type 2 diabetes mellitus, anxiety, class 3 obesity, neuromuscular dysfunction of the bladder, and neurogenic bowel, and was admitted with an indwelling urinary catheter that was to be replaced with a suprapubic catheter. The resident was cognitively intact, with a BIMS score of 15, and was their own decision maker. A grievance documented that the resident was scheduled for suprapubic catheter insertion on 12/31/25, but the facility did not ensure stretcher transportation was arranged as requested by a family member, resulting in the need to reschedule the procedure.

The surveyor’s review of the medical record and interviews with the Scheduling Coordinator revealed that transportation requests are made through the facility’s electronic medical record system and then processed by the Scheduling Coordinator or a backup staff member. The facility did not have a written policy or procedure for appointments and transportation. Initial review showed no appointment or transportation request entered for the resident’s 12/31/25 procedure. Further review identified only a last-minute call from staff to the Scheduling Coordinator’s coworker requesting stretcher transport for that date, and the facility was unable to secure stretcher transport on short notice. As a result, the resident’s appointment for suprapubic catheter placement had to be rescheduled to 1/5/26.