Latex Catheter Used for Resident With Documented Latex Allergy
Penalty
Summary
The deficiency involves the facility’s failure to follow established clinical guidelines regarding the use of latex-containing urinary catheters in a resident with a documented latex allergy. Clinical standards from an online professional journal on urology and continence care state that PTFE (a type of silicone) coated catheters are latex catheters and must be avoided in patients with known latex allergy or sensitivity due to ongoing risk of latex reaction. The facility’s medical storeroom stocked both PTFE silicone-coated latex catheters and 100% silicone, latex-free catheters intended for residents with latex sensitivity or allergies. The resident involved was admitted with multiple diagnoses including paraplegia, cervical spinal stenosis, post-laminectomy syndrome, flaccid neuropathic bladder, UTI, and anxiety disorder, and required use of a latex-free indwelling urinary catheter for urinary elimination. The resident’s MDS showed a BIMS score of 15, indicating intact cognition, and the MAR/TAR documented latex as an allergy. Despite this, a nurse’s note documented that on 8/6/2025 the resident’s leaking Foley catheter with sediment was replaced using sterile technique with a new catheter from facility stock, and there is no indication in the note that a latex-free catheter was selected, even though the resident had a known latex allergy. Subsequently, the resident reported concerns about having a latex Foley catheter in place and requested transfer to the hospital, stating she did not want to return to the facility. Hospital records documented that the resident reported a latex catheter had been inserted four days earlier despite her latex allergy and that she was experiencing burning and itching and felt she was having a reaction. In the ED, the urinary catheter was replaced with a non-latex catheter. During interview, the DON confirmed that, based on review of hospital and facility documentation, a stock silicone-coated latex catheter had been inserted for this resident in error, and that the facility failed to follow recognized standards of care related to the use of latex-containing devices in persons with known latex sensitivity.
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