Failure to Provide Proper Catheter Care Due to Supply and Communication Issues
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, who required a 20 French suprapubic catheter per physician order, was not provided with the correct catheter size due to the facility running out of supplies. Instead, an 18 French catheter was used as a temporary measure following a physician's order, with instructions to replace it with the correct size the next day. However, the 20 French catheter was not available for two days, and the resident continued with the smaller catheter, which led to leakage and discomfort. The facility's supply management process was found to be inadequate, as the staff responsible for ordering supplies did not track inventory systematically and relied on visual checks and staff notifications, resulting in the unavailability of the required catheter size. The resident's care plan and physician orders did not consistently specify the required catheter size, and there was a lack of clear documentation regarding the catheter size in use. Communication gaps were identified between nursing staff, central supply, and facility leadership, which contributed to the delay in obtaining the correct catheter. Additionally, there was confusion regarding the responsibility for ordering and tracking supplies, and the central supply clerk did not maintain a log or tracking system for inventory needs. The Director of Nursing (DON) and Nurse Practitioner (NP) were not promptly notified or did not conduct timely in-person assessments, and there was no documentation of a physician or NP visit during the critical period when the catheter issue occurred. As a result of the delay in providing the correct catheter size and the lack of timely intervention, the resident developed a urinary tract infection (UTI) and required hospitalization. The hospital records indicated that the suprapubic catheter tract closed, necessitating the placement of a urethral catheter and antibiotic treatment. The resident expressed dissatisfaction with the care received, noting that they were not kept informed about the availability of the correct catheter and did not see a physician during the incident. The facility's policies and procedures did not adequately address catheter sizing or supply management, contributing to the deficiency.