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Based on interview and record review, the facility failed to adequately assess the placement of a suprapubic catheter after insertion, in the emergency department, again after the patient was admitted to observation status, and finally during inpatient status at the hospital. The facility failed to follow infection control preventive measures when caring for the suprapubic catheter, for 1 (#1) of 7 sampled and supplemental patients. Findings include:

Review of medical records for patient #1 showed nursing staff failed to identify the misplacement of a suprapubic catheter during insertion in the emergency department. Nursing staff failed to follow proper technique when correcting the misplacement of the catheter, exposing patient #1 to unnecessary risk for infection. Please refer to deficiency at A392. Please see A749 for infection control concerns.

Based on interview and record review, the facility failed to adequately assess the placement of a suprapubic catheter after insertion, in the emergency department, again after the patient was admitted to observation status, and finally as an inpatient status at the hospital, for 1 (#1) of 7 sampled and supplemental patients. Findings include:

Review of the Emergency Department Encounter for patient #1, dated 6/10/16 at 8:21 p.m., showed the chief complaint was altered mental status, and the genitourinary status was shown to have been negative for signs and symptoms. The patient's suprapubic catheter was changed in the emergency department at 8:40 p.m. by staff member H, "per policy." A review of the clinical record did not show evidence of urine return on insertion of the suprapubic catheter. The patient was placed in observation status and ultimately admitted to the hospital.

Review of the physician assessment, dated 06/10/16 at 11:47 p.m., showed the abdomen was soft, non-tender, obese, and the patient's suprapubic catheter was in place.

Review of the All Flowsheet Data (06/10/16 0000--06/10/16 2359) showed there was no urinary output from the patient.

Review of nursing note dated 6/11/16 at 1:45 a.m., showed "Patient had 0 output from the suprapubic cath. No sample could be obtained. Bladder scanned pt for 200 [sic]. Flushed cath easily but no further urine."

Review of the All Flowsheet Data (06/11/16 0000--2359) showed a bladder scan volume of 511 ml at 11:14 a.m. And a total of 550 ml urinary output by 7:31 p.m.

A review of the narrative nursing note for 6/11/16 at 6:56 p.m., written by a student nurse and edited by staff member G, showed nursing had turned the patient and noticed the catheter tip was visible; the catheter was repositioned and was draining.

During an interview on 6/30/16 at 9:20 a.m., staff member G said while providing care for patient #1 on 6/11/16, they turned her over to clean her because she had BM. The tip of the suprapubic catheter and the bulb (balloon) were sticking out from the urethra into the vaginal area (A supra pubic catheter enters the body through the abdominal wall and directly into the urinary bladder. The catheter would have traveled through the bladder, down the urethra, and out into the vaginal area prior to the bulb being inflated). Staff member G said she was assisted in caring for patient #1 by a student nurse and two of patient #1's significant people from the community. Patient #1 was wet with urine and had a bowel movement, and needed to be cleaned up. Staff member G said it was during this care activity that the catheter tip and balloon were noted in the vaginal area. Staff member G said she deflated the bulb (balloon) of the catheter and pulled the tube back through the urethral meatus. As soon as the tip disappeared into the bladder she observed urine flow through the catheter; about 800 ml. After the flow stopped, she contacted the shift doctor and was told if she got urine flow, the catheter was in the right place and to go ahead and re-inflate the catheter balloon. Staff member G said prior to the retraction of the catheter, there had been no urine output seen in the catheter bag. Staff member G said she had received a report from the night shift nurse that the catheter had been flushed without a problem and they still could not figure out why there was no urine output. Staff member G said she and the night nurse each scanned the bladder for urine. She said she was just about to straight cath patient #1 when she discovered the catheter tip and bulb were outside the urethra and in the vaginal area. Staff member G retracted the catheter into the bladder, but did not change out the catheter even though patient #1 had been wet with urine and feces.

During a confidential phone interview on 6/29/16 at 2:10 p.m., public member BB said she was present with public member AA, and assisted the RN and student nurse in turning and cleaning the patient of urine and feces. She said, "The bedding was soaked," and " I saw the entire catheter balloon and end of the catheter protruding from her vagina."

During a confidential phone interview on 6/16/16 at 9:05 a.m., public member AA said she witnessed the catheter balloon in the vaginal area and said the nurse retracted the balloon back into the bladder. The nurse did not apply a new catheter. AA said she was at the hospital around the lunch hour. From 8:40 p.m., when the catheter was placed in the emergency department, until 12:00 p.m. the following day, would have been 15 hrs and 20 minutes

A review of Lippincott Procedures-Suprapubic catheter replacement, provided by the facility, showed, "As urine begins to drain from the catheter, insert the catheter approximately 2" (5cm) farther to make sure that the catheter is in the bladder and not the suprapubic tract."

A review of Lippincott Procedures-Suprapubic catheter care, provided by the facility, showed, "Inspect the catheter insertion site for drainage, and inspect the surrounding skin for redness or swelling. Notify the practitioner if these signs are present." And, "Monitor the patient's urine intake and output. Observe the urine for appearance, odor, color, and any unusual characteristics. Monitor for signs of infection, such as increasing suprapubic pain or tenderness, fever, and tachycardia."

Based on interview and record review, staff did not practice infection prevention measures when correcting placement problems with a suprapubic catheter for 1 (#1) of 7 sampled and supplemental patients. Findings include:

During an interview on 6/30/16 at 9:20 a.m., staff member G said while providing care for patient #1 on 6/11/16, they turned her over to clean her because she had BM. The tip of the suprapubic catheter and the bulb (balloon) were sticking out from the urethra into the vaginal area (A supra pubic catheter enters the body through the abdominal wall and directly into the urinary bladder. The catheter would have traveled through the bladder, down the urethra, and out into the vaginal area prior to the bulb being inflated). Staff member G said she was assisted in caring for patient #1 by a student nurse and two of patient #1's significant people from the community. Patient #1 was wet with urine and had a bowel movement, and needed to be cleaned up. Staff member G said it was during this care activity that the catheter tip and balloon was noted in the vaginal area. Staff member G said she deflated the bulb (balloon) of the catheter and pulled the tube back through the urethral meatus. As soon as the tip disappeared into the bladder she observed urine flow through the catheter, about 800 ml. Staff member G retracted the catheter into the bladder, but did not change out the catheter even though patient #1 had been wet with urine and feces.

A review of the narrative nursing note for 6/11/16 at 6:56 p.m., written by a student nurse and edited by staff member G, showed nursing had turned the patient and noticed the catheter tip was visible; the catheter was repositioned and was draining.

A review of Lippincott Procedures-Suprapubic catheter replacement, provided by the facility, showed, when inserting a suprapubic catheter into the bladder sterile technique should be used.