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F0657
D

Failure to Revise Care Plan After Catheter Removal

Winter Haven, Florida Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately revise the care plan and related interventions for a resident with a history of an indwelling urinary catheter. The resident's care plan continued to include interventions and goals related to catheter care, even after the catheter had been removed. Observations and interviews confirmed that the resident did not have a urinary catheter at the time of the survey, and the resident reported that the catheter had come out approximately three weeks prior. Documentation review showed that the catheter was found on the bed with the balloon deflated, and the physician had ordered it to be left out to monitor the resident's condition without it. Despite the removal of the catheter and the absence of a current physician order for catheter use, the care plan was not updated in a timely manner to reflect the resident's current status. Staff interviews revealed confusion regarding the resident's catheter status, with some staff initially believing the resident still had a catheter. The facility's policy requires that comprehensive care plans be developed and revised to reflect the resident's current needs, but this was not followed in this case.

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