Failure to Develop and Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling Foley catheter, as required by federal regulations. Despite the resident's significant medical history, including cancer, cerebrovascular accident, metabolic encephalopathy, and severe cognitive impairment (BIMS score 5/15), there was no care plan addressing the management and care of the Foley catheter. The resident had physician orders for specific catheter care, including monthly changes, care every shift, and monitoring for complications, but these were not reflected in the resident's comprehensive care plan. Observations and record reviews revealed that the resident was confused, unable to respond to questions, and had a Foley catheter drainage bag improperly positioned on the floor with the catheter strap detached. Interviews with the DON and Administrator confirmed that care planning is a team responsibility and should be updated upon admission and with any change in condition. Facility policies also require daily review of care plans for changes, but this was not done for the resident's Foley catheter, resulting in the deficiency.