Failure to Use Correct Catheter Size During Suprapubic Catheter Care
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with a diagnosis of neuromuscular dysfunction of the bladder, who had a physician's order for a 20 French suprapubic catheter. The resident's care plan directed staff to change the catheter monthly and as needed. However, staff inserted a 12 French catheter instead of the ordered 20 French size. When an attempt was made to replace the incorrect catheter with the correct size, the nurse was unable to insert the 20 French catheter after several attempts and ultimately reinserted the 12 French catheter. The incident was documented in the resident's progress notes, and the resident was later seen by a urologist who placed a 16 French catheter. The facility's policy required staff to use the proper catheter size as ordered and to report any complications. Interviews with administrative nurses confirmed the expectation that staff use the correct catheter size. The error in catheter size selection and the subsequent difficulty in correcting it constituted a failure to follow physician orders and facility policy, resulting in a deficiency in catheter care for the resident.