Care Plan Not Updated for Resident's Catheter Removal
Penalty
Summary
A deficiency was identified in the care planning process for a resident with type 2 diabetes mellitus and stage 3 chronic kidney disease. The resident's care plan was not updated to reflect the removal of an indwelling catheter, which had been removed as per hospital notes dated October 26, 2024. Despite the removal of the catheter, the care plan continued to list it as part of the resident's care needs. The oversight was discovered during a review of the resident's clinical records and was confirmed through observation and staff interviews. The Medication and Treatment Records for February 2025 did not include any orders for an indwelling catheter, further indicating that the care plan was outdated. The Nursing Home Administrator acknowledged the issue in email correspondence, confirming the deficiency in the care planning process.
Plan Of Correction
1. Education to Licensed staff, to ensure that care plans are updated timely to reflect current and accurate resident care plan. 2. Resident care plans for residents with current indwelling catheters, and residents that have had indwelling catheters discontinued over the last 30 days will be audited for accuracy. 3. DON or designee Audits for accurate care plan documentation for Residents with discontinued and current indwelling catheters will continue weekly for 4 weeks, monthly for 2 months. 4. Audits and findings will be submitted in the Quarterly QAPI committee meetings.