Failure to Ensure Adequate Intermittent Catheter Supply for Self-Catheterizing Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure an adequate supply of urinary catheters was available for a resident who performed intermittent self-catheterization. The resident had diagnoses including paraplegia and neuromuscular dysfunction of the bladder, with a care plan noting risk for infection related to neurogenic bladder and the need for intermittent self-catheterization. A physician visit note documented that the resident reported running low on straight catheters, expressed concern about being forced to reuse catheters, and referenced a history of recurrent UTIs with sepsis. The physician emphasized the importance of sterile, single-use technique and ordered 16F straight catheters for intermittent catheterization. Despite this order and plan, the resident reported ongoing problems obtaining sufficient catheter supplies and interruptions in his catheterization schedule. He stated he was supposed to catheterize every 4–6 hours, understood the plan, and was motivated to adhere to it, but indicated that on the survey day he had been asking since the morning for catheters and had not emptied his bladder since the previous night. He reported that staff were only giving him four catheters for the day instead of at least five as he had been told by the medical provider, and that he sometimes had to reuse catheters at night when staff either did not know where supplies were or reported that supplies were gone. During an interview, he showed his bedside drawer, which contained only three new packaged catheters, which he indicated was all he would receive for the day. Staff interviews and observations further demonstrated gaps in ensuring adequate catheter availability. The nurse practitioner confirmed the resident should receive enough catheters to empty his bladder at least every 4–6 hours and as needed, depending on fluid intake. The QMA responsible for ordering catheters stated she had previously given the resident nearly a full box of 20 catheters over a weekend and believed he was to catheterize every 8 hours; she was unaware that the frequency had changed to every 4–6 hours because nursing staff had not updated her. At the time of observation, there was a box with nineteen 16F catheters for the resident in the supply room, and evening and night staff had access to that room, yet the resident still had only a limited number of catheters at bedside. The nurse consultant acknowledged that the facility did not have a policy for self-catheterization that addressed the availability of supplies.
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