Failure to Update Care Plan After Change in Continence Status
Penalty
Summary
A deficiency was identified when the facility failed to update a resident's care plan to reflect a significant change in their care needs. The resident, who had a history of obstructive uropathy and previously required an indwelling urinary catheter, had the catheter discontinued per physician's orders. Following the removal of the catheter, documentation showed that the resident was frequently incontinent of bladder. Despite this change, there was no evidence in the clinical record that the resident's care plan was revised to address the new incontinence status. The facility's policy required care plans to be reviewed and revised with significant changes in condition, but as of the date of review, the care plan had not been updated to reflect the resident's bladder incontinence. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
Resident 13's care plan was revised/updated to reflect her bladder incontinence since removal of her indwelling urinary catheter on April 15, 2025. Any resident who has their indwelling urinary catheter removed has the ability to be affected by this alleged deficient practice. A whole house audit of residents recently having their indwelling urinary catheter removed was completed to ensure his/her care plan has been revised to reflect their current bladder continence/incontinence status. Licensed nursing staff, including agency licensed nursing staff, re-educated on the importance of updating/revising resident care plans to reflect resident-specific care needs, including residents who have their indwelling urinary catheter removed to include his/her bladder continence/incontinence status in the care plan. Licensed Practical Nurse Assessment Coordinator will routinely review order summary reports to ensure resident care plans are updated/revised with changes, new orders, and/or discontinued orders that reflect a change to the resident's current plan of care. Interdisciplinary Care Plan Team will continue to review care plans upon resident admissions, at regularly scheduled care plan conferences, and as needed to ensure individualized, person-centered care needs are included and up to date in resident care plans. The Director of Nursing/designee will audit care plans for residents who have had their indwelling urinary catheter removed weekly times twelve weeks and then monthly times four months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times seven months or until substantial compliance is noted. Licensed Practical Nurse Assessment Coordinator/designee will conduct random audits of resident care plans to ensure that all person-centered care needs are included/updated to reflect the resident's current care needs weekly times fifteen weeks, then monthly times four months, and then reviewed by the Quality Assurance and Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times eight months or until substantial compliance is noted.