Failure to Implement Person-Centered Care Plan for Urostomy Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a person-centered care plan for a resident with a urostomy, as required by federal regulations. The resident, who had diagnoses including multiple sclerosis, a malignant neoplasm of the bladder, and acute pyelonephritis, was admitted with a care plan intervention to monitor, record, and report signs and symptoms of urinary tract infection (UTI) to the physician. The care plan specifically listed symptoms such as cloudy urine, presence of sediments, and other indicators of infection that should prompt physician notification. On the day of the incident, observations revealed that the resident's urinary tubing contained cloudy urine with white sediments. The Assistant Director of Staff Development confirmed these findings and stated that the Certified Nursing Assistant (CNA) should have reported this to the Licensed Vocational Nurse (LVN). However, the CNA admitted to noticing the cloudy urine but did not report it to the LVN. The LVN only became aware of the issue after being informed later and acknowledged that such findings are possible signs of infection and should be reported to the physician without delay. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that the care plan was not followed, as the physician was not notified about the abnormal urine findings. The facility's policy required that any abnormalities in urine output, such as sediments or changes in color, be reported to the physician. The failure to follow the care plan and notify the physician as required constituted the deficiency.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 4/30/35, Treatment Nurse immediately replaced urostomy tubing and bag for Resident 1. The care plan was updated by LVN 1 on 4/30/25, and the physician was notified. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: Infection Control Nurse on 4/30/25 completed a facility audit of all residents with Foley catheter to check for sedimentation and cloudiness in the output. Additionally, IP Nurse verified all care plans were in place for all residents with Foley catheter on 4/30/25. All residents with Foley Catheter have care plans in place. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: DON performed one-to-one in-service on 4/30/25 to CNA 1 regarding prompt reporting of any cloudy urine or sediment present in the urinary tubing and catheter bag to the LVN. DON performed one-to-one in-service on 4/30/25 to LVN 1 regarding prompt reporting to MD of any cloudy urine, sediment, blood in urine, and/or change in condition. Additionally, DON reviewed the facility policy and procedure "Comprehensive Person-Centered Care Plans". DON performed licensed staff in-service to LVNs and RNs on 4/30/25, 5/1/25, and 5/2/25 regarding prompt reporting to MD of any cloudy urine, sediment, blood in urine, and/or change in condition. Additionally, DON reviewed the facility policy and procedure "Comprehensive Person-Centered Care Plans". How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. Medical records department to audit care plans weekly for three months for residents with Foley catheter, to ensure care plan is being followed. Director of Nursing to collect and review data and will report audit findings to the Quality Assurance Committee monthly for three months for review and evaluation. The Director of Nursing and/or Administrator to determine if continued auditing and monitoring is recommended after three months. Completion Date 5/22/25