Failure to Develop Care Plans for Residents with Indwelling Urinary Catheters
Penalty
Summary
The facility failed to develop and implement care plans with specific interventions for two residents who had indwelling urinary catheters in place. For both residents, medical records and physician orders documented the presence of indwelling urinary catheters, including details such as catheter size, reason for use, and instructions for changing the catheter and drainage bag. However, a review of their care plans revealed no documentation or individualized plans addressing the care and monitoring of the catheters. This omission meant that care needs related to catheter use, such as monitoring for infection, displacement, or blockage, were not formally identified or documented in the residents' care plans. Interviews with facility staff, including an LVN and the DON, confirmed that care plans should have been created to guide staff in monitoring, documenting, and reporting any signs of infection or complications associated with catheter use. The facility's own policy required comprehensive care plans with measurable objectives and timetables to address each resident's needs, but this was not followed for the two residents with indwelling catheters. As a result, the care needs related to the use of these catheters were unknown and undocumented.