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F0656
D

Failure to Include Indwelling Urinary Catheter in Comprehensive Care Plan

Ocoee, Florida Survey Completed on 05-17-2025

Penalty

Fine: $114,990
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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 develop an individualized Comprehensive Care Plan that addressed the use of an indwelling urinary catheter for a resident who was admitted from an acute care hospital with multiple diagnoses, including a wedge compression fracture and a urinary tract infection (UTI). The resident was moderately cognitively impaired, required staff assistance for activities of daily living, and had an indwelling urinary catheter in place. Medical records indicated the resident was prescribed antibiotics for a UTI and required the insertion of a urinary catheter due to inability to urinate. Despite the Care Area Assessment (CAA) triggering the need for inclusion of the indwelling urinary catheter in the Comprehensive Care Plan, the care plan completed and revised during the resident's stay did not include any focus, goals, or interventions related to the catheter. The MDS Coordinator confirmed that the omission was an oversight, acknowledging that the catheter was not addressed in the care plan as required by facility policy and assessment findings.

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