Failure to Develop and Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's Foley catheter care as ordered by the physician. The resident, who had a history of left femur fracture, left artificial hip joint, and unspecified fall, was admitted and readmitted to the facility. The Minimum Data Set assessment indicated the resident had severely impaired cognitive skills and was dependent on staff for all activities of daily living. Despite physician orders for Foley catheter care and monitoring of urine output, there was no corresponding care plan documented or implemented in the resident's records. Interviews with facility staff, including an LVN, medical records staff, and the Director of Nursing, confirmed that no care plan was developed or updated to address the Foley catheter care and urine output monitoring. The facility's own policy requires the interdisciplinary team to develop a comprehensive, person-centered care plan for each resident, incorporating measurable objectives and timetables, and to update the plan with any new physician orders or changes in the resident's condition. This policy was not followed in the case of this resident.