Failure to Include Catheter Care in Baseline Care Plan
Penalty
Summary
The facility failed to address catheter care needs for a resident with a diagnosis of neuromuscular dysfunction of the bladder and neurogenic bladder, who was unable to bear weight and required assistance with activities of daily living. The resident's electronic medical record documented the presence of a Foley catheter with dependent drainage, initiated to manage her bladder condition and prevent skin breakdown. Despite this, the baseline care plan created upon admission did not include any documentation or instructions regarding the resident's catheter or its care, focusing only on wound assessment and pain management. Observations revealed the resident in bed with a catheter bag containing dark red urine, and staff interviews confirmed that the resident consistently had red, dark urine. Certified Medication Aides reported referencing the matrix for care information, and administrative nursing staff acknowledged that catheter care should have been included in the baseline care plan. The facility's policy required a baseline care plan to be developed and implemented within 48 hours of admission to address immediate care needs, which was not followed in this case.