Failure to Revise Care Plan and Ensure Interdisciplinary Team Participation
Penalty
Summary
Facility staff failed to review and revise the care plan for a resident who was performing self-catheter care. The resident, who had a history of neuromuscular bladder dysfunction and multiple urinary tract infections, was observed performing his own Foley catheter care. The care plan did not reflect that the resident was independently managing this aspect of his care, and staff interviews revealed a lack of awareness and guidance regarding the resident's self-care practices. The CNA involved was not informed to assist with catheter care beyond emptying the Foley, and the LPN stated that CNAs were responsible for catheter care as part of ADLs. The Assistant Director of Nursing acknowledged that CNAs should help with Foley care and indicated a need for resident education on proper care techniques. Additionally, the facility failed to ensure that the interdisciplinary team (IDT) was present at care plan meetings for two residents. For one resident with Wernicke's encephalopathy and intact cognitive status, care conference records showed that only social services staff and the resident or responsible party attended, with no participation from other required departments such as nursing, dietary, or therapy. The resident did not recall attending any care conferences and had ongoing concerns about social security, community transition, and personal belongings that were not addressed in these meetings. For another resident with severe cognitive impairment due to dementia, care conference records similarly indicated that only social services staff and a family member attended, with no other departments present. The family member reported inconsistent communication about care changes and concerns regarding pressure ulcers, activity participation, and hydration. Staff interviews confirmed that nursing and other departments were not consistently invited or present at care conferences, and there was no system in place to ensure attendance or documentation of participation. The Social Services Director cited staffing shortages as a reason for the lack of interdisciplinary involvement and did not escalate the issue to administration.