Failure to Include Indwelling Catheter in Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who was readmitted with an indwelling catheter. The resident had multiple diagnoses, including type 2 diabetes mellitus, obstructive uropathy, and reflux uropathy, and required staff assistance for daily activities. Physician orders indicated the need for indwelling catheter care every day shift for 30 days due to neurogenic bladder. However, upon review, the baseline care plan did not address the presence of the indwelling catheter or specify related care interventions. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed that the baseline care plan was incomplete and did not reflect the resident's catheter or the necessary care instructions. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including all immediate health and safety needs, but this was not followed in the resident's case. The omission was identified through record review and staff interviews, highlighting a failure to document and plan for the resident's catheter care needs upon admission.