Failure to Include PICC and Suprapubic Catheter Care in Baseline Care Plan
Penalty
Summary
Facility staff failed to include essential initial care needs for a resident who was admitted with a peripherally inserted central catheter (PICC) and a suprapubic urinary catheter. The resident's baseline care plan, created within 48 hours of admission, did not mention the presence of the PICC or the suprapubic catheter, nor did it address specific care needs related to these devices. The baseline care plan only referenced toileting assistance for bowel/bladder needs and contact precautions for infection control, omitting any mention of the urinary catheter and PICC care requirements. Interviews with the registered nurse unit manager and the director of nursing confirmed that the resident was admitted with both a PICC and a suprapubic catheter, and that these were not included in the baseline care plan. The facility's policy requires that the baseline care plan include the minimum health care information necessary to care for a resident, based on admission orders and assessments. The omission was identified during a review of the clinical record, staff interviews, and facility documentation, with no additional information provided by facility leadership prior to the end of the survey.