Failure to Individualize and Accurately Document Catheter Balloon Size in Care Plans
Penalty
Summary
The facility failed to individualize and accurately document comprehensive care plans for urinary catheter bulb size for two residents who required catheter care. For one resident with severe cognitive impairment and urinary retention, the physician order specified an 18 French catheter with a 5 cc balloon, but the care plan incorrectly listed a 10 cc balloon. For another resident with a history of prostate and bladder cancer, chronic self-catheterization, and intact cognition, the physician order specified a 16 French catheter with a 10 cc balloon, while the care plan referenced a 14 French catheter with a 10 ml balloon. These discrepancies were identified through clinical record review, policy review, and staff interview. Facility policy requires that all physician orders, including specific instructions such as catheter and balloon size, be accurately documented and reflected in the resident's care plan. The care plans are to be developed by an interdisciplinary team and must include measurable goals and timetables based on the comprehensive assessment. The Director of Clinical Excellence confirmed that the care plan should match the physician order for catheter balloon size, as this is a standard of care. The failure to ensure consistency between physician orders and care plans for catheter care was observed for both residents reviewed.