Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling urinary catheter. Despite the resident having a catheter from late January to early April, the comprehensive care plan did not include a care area addressing the catheter, its management, or related interventions. The baseline care plan and physician orders documented the presence and care requirements for the catheter, but this information was not carried over to the comprehensive care plan, leaving a gap in the documentation and communication of care needs. The resident in question had significant medical complexities, including chronic kidney disease stage 4, type 2 diabetes mellitus, hypertensive heart disease with heart failure, and a cognitive communication deficit. The resident was dependent on staff for toileting and had a history of urinary tract infection and renal insufficiency. Although the care plan addressed risks related to renal failure, skin breakdown, and urinary incontinence, it did not specifically address the indwelling catheter, its care, or monitoring for complications such as infection or obstruction. Interviews with facility staff, including the DON and MDS Nurse, confirmed that the catheter was not included in the comprehensive care plan. The MDS Nurse acknowledged that the catheter was documented in the baseline care plan and MDS but was not transferred to the comprehensive care plan. Both the DON and MDS Nurse recognized that the omission could result in staff not being informed about the catheter care requirements, which could lead to negative outcomes such as infection. The facility's policy required that care plans include measurable objectives and timeframes for all identified needs, but this was not followed in this case.