F0690

D

Incorrect Urinary Catheter Size Used Contrary to Physician Order

Springfield, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident with an indwelling urinary catheter received the correct catheter size as ordered by the physician and outlined in the care plan. The resident was admitted with diagnoses including quadriplegia and neuromuscular dysfunction of the bladder, and had intact cognition but required total staff assistance for bed mobility, transfers, and toileting. The resident’s care plan specified a Mitrofanoff catheter 12 French (F) with a 10 cubic centimeter (cc) balloon to be changed every 30 days, and the physician’s order directed that this 12F/10 cc Mitrofanoff catheter be changed on the 28th of each month.

Review of the medical record showed no documentation on the medication administration record of any urinary catheter change for the resident in the month of March prior to the observation of the incorrect catheter. Progress notes from 03/01/25 to 03/22/25 were also silent regarding any catheter changes. During an observation with an LPN on 03/17/26, the resident was found to have a 14F/10 cc catheter in place instead of the ordered 12F/10 cc catheter. The LPN confirmed the catheter size was incorrect and stated that the catheter should be 12F/10 cc, but did not know how long the 14F/10 cc catheter had been in place.