Failure to Develop and Implement Comprehensive Care Plans for Residents with Urinary Catheters
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents who had indwelling urinary catheters. Despite documentation in the Minimum Data Set (MDS) assessments and physician orders indicating the presence of catheters, the residents' care plans did not reflect this critical aspect of their care. For example, one resident's initial care plan did not mention her indwelling catheter, even though her MDS assessment and direct observation confirmed its use. Another resident's care plan, closed upon discharge, also lacked any reference to her catheter, despite hospital records and physician orders indicating its necessity and ongoing use. Observations and interviews further revealed that staff were aware of the residents' catheters through direct care and visual cues, but this information was not formally documented in the care plans. One resident was observed moving through the hallway with her catheter bag visible and without a privacy cover, and she reported that this was a common occurrence. Another resident expressed confusion and distress about her catheter, frequently asking staff for its removal, yet her care plan did not address her catheter use or her psychosocial needs related to it. Staff interviews confirmed that catheter care was provided based on standard practice and observation rather than individualized, documented care plans. The lack of documentation and individualized care planning for catheter use was consistent across multiple residents, as evidenced by the absence of catheter-related goals, interventions, or measurable objectives in their care plans. This omission was noted despite facility policy requiring comprehensive, person-centered care plans that include measurable objectives, timeframes, and descriptions of services to meet each resident's needs. The failure to include catheter care in the care plans placed residents at risk of not having their needs for assistance met and increased their susceptibility to urinary tract infections (UTIs).