Failure to Develop and Implement Care Plan for Resident Refusing Catheter Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions for a resident who refused indwelling urinary catheter care. The resident, who was admitted with diagnoses including epilepsy, Parkinson's disease, and urinary retention, had documented moderate cognitive impairment and was dependent on staff for toileting hygiene. Despite multiple documented refusals of disposable brief changes and catheter care, there was no care plan created to address these refusals or to guide staff in managing the resident's needs related to urinary catheter care and toileting hygiene. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, confirmed that no care plan was initiated after the resident's refusals, and that such a plan is necessary to address the resident's problems and guide staff actions. Review of facility policies indicated that individualized care plans should be developed and revised as residents' conditions change, and that refusals of treatment should prompt notification of the attending physician. The lack of a care plan in this situation resulted in the resident's needs not being addressed as required by facility policy.