Incomplete Baseline Care Plan for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review of the resident's admission records, assessments, and physician orders, it was found that although the baseline care plan noted the presence of an indwelling catheter, it did not include any nursing interventions or instructions for the care and monitoring of the catheter. The resident had diagnoses including type 2 diabetes mellitus, obstructive uropathy, and reflux uropathy, and required substantial to maximal assistance with activities of daily living. Physician orders specifically indicated the need for daily catheter care, but this was not reflected in the baseline care plan. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the baseline care plan was incomplete and did not address the required interventions for the resident's catheter. The facility's policy requires that a baseline care plan be developed within 48 hours of admission to address immediate health and safety needs, including all necessary services and treatments. The omission of catheter care interventions in the baseline care plan constituted a failure to meet this requirement for the resident.