Failure to Implement Comprehensive Care Plan for Resident with Indwelling Urinary Catheter
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident with an indwelling urinary catheter. The resident had a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, and was at risk for urinary tract infection due to the catheter. The care plan noted the need to monitor the catheter and urine characteristics and to report findings to the attending physician, but these interventions were not fully carried out. Observations and interviews revealed that nursing staff noted dark yellow, blood-tinged, and cloudy urine in the resident's catheter, and the catheter tubing was not properly anchored. Despite these findings, the appearance of the urine was not reported to the physician as required. Additionally, after the resident returned from a hospital stay, catheter care orders were not reordered, and there was no documented evidence that catheter care was provided during this period. The Director of Nursing confirmed that the care plan was not followed, and the resident's catheter was not monitored or reported for visible hematuria. Facility policies required comprehensive care plans and complete documentation of services and changes in condition, but these were not adhered to in this case, resulting in a failure to address the resident's identified needs related to the indwelling urinary catheter.