Failure to Develop and Implement Comprehensive Care Plans for Indwelling Catheter and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the management of an indwelling urinary catheter and oxygen therapy. For one male resident with multiple diagnoses, including metabolic encephalopathy, peripheral vascular disease, osteoporosis, atrial fibrillation, and acute urinary retention, there was no care plan addressing his indwelling urinary catheter following a recent hospitalization and procedure. Despite clear documentation in hospital records, physician orders, and nursing notes regarding the presence and management of the catheter, the resident's care plan did not include this information at the time of review. Interviews with facility staff confirmed the absence of a care plan for the catheter, and staff acknowledged that such a plan was necessary to guide care. Another female resident with complex medical needs, including a tracheostomy, chronic kidney disease, pressure ulcer, hypertension, encephalopathy, urinary retention, gastrostomy, muscle weakness, dysphagia, diabetes, chronic pain, and chronic respiratory failure, was also found to have an incomplete care plan. Although physician orders and the Minimum Data Set (MDS) assessment indicated that she was receiving continuous oxygen therapy via tracheostomy, her care plan did not address this intervention. Observations confirmed the resident was on oxygen, and staff interviews revealed awareness of her oxygen use but also acknowledged the lack of a corresponding care plan. The facility's policy requires the interdisciplinary team to develop comprehensive, person-centered care plans based on resident assessments. In both cases, the care plans failed to include measurable objectives and time frames for the identified needs, specifically the indwelling urinary catheter and oxygen therapy. This omission was confirmed through record review, staff interviews, and direct observation, demonstrating a failure to ensure that care plans accurately reflected the residents' current conditions and required interventions.