Failure to Secure Suprapubic Catheter and Follow Ordered Catheter Size
Penalty
Summary
Surveyors identified that a resident with neuromuscular bladder dysfunction, quadriplegia, aphasia, tracheostomy, and severe cognitive impairment (BIMS score of 0) did not receive appropriate treatment and services related to an indwelling suprapubic catheter. The resident’s care plan documented an indwelling 18 FR suprapubic catheter with an intervention to ensure a statlock was in place to secure the Foley tubing to prevent injury. The physician’s order summary, however, directed that a 16 FR/30 ml suprapubic catheter be exchanged every four weeks and as needed, and that the suprapubic catheter be secured with a statlock. Record review of the MAR showed that on a specified date at 2:20 a.m., an LVN changed the resident’s suprapubic catheter and documented insertion of a 16 FR/30 ml catheter. During observation later that morning, surveyors noted the resident in bed with the suprapubic catheter unsecured and without a statlock or other leg securement device in place. The catheter in place was labeled 18 FR/30 ml, which did not match the physician’s order for a 16 FR catheter. A subsequent observation confirmed that both 16 FR and 18 FR catheters were available in the facility’s supply room. In interviews, an LVN stated the resident had an order for a 16 FR suprapubic catheter since a specified date but currently had an 18 FR catheter in place, and acknowledged she was unaware the catheter was unsecured and that nurses were responsible for verifying catheter size and securement at the start of their shifts. The ADON confirmed the order for a 16 FR suprapubic catheter, acknowledged that an 18 FR catheter had been placed by an LVN, and stated he was not aware the wrong size catheter was in place. The DON also stated she was not aware the catheter was unsecured or that the wrong size (18 FR instead of 16 FR) had been used, and affirmed that nurses were responsible for verifying and correctly implementing physician orders, including inserting the correct catheter size and securing it. Facility policy on urinary catheter care required that catheters remain secured with a securement device to reduce friction and movement at the insertion site.
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