April 17 2013_NH "Dear Administrator"

April 17, 2013

ALTSA: NH #2013-005

Dear Nursing Facility/Home Administrator:

The purpose of this letter is to let you know that the Centers for Medicare & Medicaid Services (CMS) has issued a survey and certification (S&C) letter about the dangers of a Luer misconnection and the safeguards necessary to prevent adverse events. In the S&C, CMS provided several examples of where Luer misconnections led to patient deaths.

According to CMS guidance, there are certain actions which can be taken by the nursing home to reduce the likelihood of a Luer misconnection:

  • Tracing lines back to their origins when reconnecting devices;
  • Positioning catheters and tubes that have different purposes on different sides of the patient's body or in unique standardized directions;
  • Implementing a multi-disciplinary facility approach to address Luer misconnections;
  • Changing to devices already on the market with alternative connector designs which reduce the likelihood of misconnections of incompatible lines.
  • Reviewing this information in facility Quality Assessment and Performance Improvement (QAPI) program meetings

The Food & Drug Administration (FDA) has a website which provides case studies and additional resources about Luer misconnections and how to prevent them at https://www.fda.gov/medical-devices/medical-device-connectors/examples-medical-device-misconnections.

To read the details of the memorandum online, please visit:

Please note the Quality Indicator Survey process has not changed.  Contact your local RCS Field Manager if you have any questions.


Joyce Pashley Stockwell, Director
Residential Care Services