Failure to Document Catheter Care in Baseline Care Plan
Penalty
Summary
The facility failed to address catheter care in the baseline care plan for a resident who was admitted with a Foley catheter. The resident, who has mild cognitive impairment, was admitted with diagnoses including Hemiplegia, Hemiparesis following Cerebral Infarction, Urinary Tract Infection, and Dysuria. During an interview, the resident expressed uncertainty about the reason for having a catheter, indicating a lack of communication or documentation regarding his catheter care. A review of the resident's baseline care plan showed no documentation about the Foley catheter, which was acknowledged by the MDS coordinator as an oversight. The coordinator noted that the baseline care plan was currently effective, as the comprehensive care plan could not yet be printed, and confirmed that the catheter should have been included in the baseline care plan.