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F0657
D

Failure to Update Care Plan After Foley Catheter Removal

Big Lake, Texas Survey Completed on 05-15-2025

Penalty

No penalty information released
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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 update and revise the care plan for a resident after the removal of an indwelling urinary Foley catheter. The resident, who had diagnoses of overactive bladder and Parkinson's disease, was admitted with a Foley catheter in place due to benign prostatic hyperplasia with urinary retention. Although the catheter was discontinued per physician order and documented in the nursing notes, the care plan continued to list interventions and goals related to catheter care. Multiple staff interviews confirmed that the resident no longer had a catheter, and the resident himself reported using a urinal instead. However, the care plan was not updated to reflect this change in the resident's status. The MDS coordinator acknowledged that the care plan should have been revised to remove references to the indwelling catheter after its discontinuation, but this update was missed. The facility's policy requires care plans to be revised as resident conditions change, and the Director of Nursing confirmed that the MDS coordinator is responsible for these updates. The failure to revise the care plan was identified through record review, staff interviews, and direct observation, demonstrating a lapse in ensuring that care plans accurately reflect current resident needs.

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