Failure to Address Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review, it was found that the baseline care plan did not address the resident's indwelling catheter, despite the resident having diagnoses including type 2 diabetes mellitus, obstructive uropathy, reflux uropathy, and benign prostatic hyperplasia. The resident required varying levels of assistance for activities of daily living and had a physician's order for catheter care, including cleansing and monitoring for signs of infection every shift. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the baseline care plan was incomplete and did not include interventions for the indwelling catheter. The facility's policy required a baseline care plan to be developed within 48 hours of admission, addressing all care areas and necessary nursing interventions. The omission was acknowledged by staff, who stated that the baseline care plan must be thorough to meet the resident's immediate care needs.