Failure to Revise Care Plan After Catheter Discontinuation
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by an interdisciplinary team for one resident who was admitted with an indwelling catheter. The resident's care plan, initially created to address catheter care, was not updated after the catheter was discontinued. Documentation showed that the care plan continued to list catheter-related interventions and goals, even though the resident no longer had a catheter. This oversight was confirmed through interviews with both the MDS Coordinator and the DON, who acknowledged that the care plan should have been revised to reflect the resident's current status. The resident, who was cognitively intact and had diagnoses including hypertension, diabetes, lack of coordination, and muscle weakness, reported that the catheter was removed after a short period and that she was now voiding on her own. Despite this change, the care plan remained unchanged, and the facility's policy required care plans to be updated when a resident's condition changes. The failure to revise the care plan was attributed to it being overlooked by the interdisciplinary team.