Failure to Revise Care Plan for Catheter Bag Placement
Penalty
Summary
The facility failed to review and revise the Comprehensive Care Plan (CCP) for one resident who consistently placed his catheter bag on the floor, despite repeated observations and interviews confirming this behavior. The resident, who was cognitively intact and had a history of benign prostatic hyperplasia, peripheral vascular disease, hypertension, and chronic kidney disease, was care planned for urinary catheterization and related risks, but the care plan did not address his specific practice of placing the catheter bag on the floor. Multiple observations over several days documented the catheter bag lying on the floor without a dignity cover, and the resident stated his preference for keeping the bag on the floor so he could see the urine output. Facility policies required that care plans be person-centered, revised as necessary, and incorporate identified problem areas and risk factors. The Catheter Associated Urinary Tract Infection (CAUTI) Prevention policy specifically stated that catheter bags and tubing should be kept off the floor. Despite these policies and the resident's ongoing behavior, the CCP was not updated to reflect the resident's actions or the education provided to him regarding the risks of placing the catheter bag on the floor. Interviews with staff, including nurse aides, the unit manager, LPN, assistant directors of nursing, and the director of nursing, confirmed that the resident repeatedly placed his catheter bag on the floor and that staff had educated him about the importance of keeping the bag off the floor. However, there was no documentation in the resident's medical record of this education or any updates to the care plan to address the issue. The failure to revise the care plan and document interventions and education represented a deficiency in the facility's care planning process.