Failure to Develop Baseline Care Plan for Catheter Care Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. The resident was admitted with multiple complex diagnoses, including malignant neoplasm of the uterus, acute respiratory failure, a left femur fracture, a pressure ulcer, constipation, dependence on supplemental oxygen, generalized anxiety disorder, lymphedema, malignant melanoma, and obstructive and reflux uropathy. Documentation showed the resident was incontinent of bladder and had a Foley catheter inserted prior to admission. However, the admission evaluation did not accurately reflect the presence of the Foley catheter or obstructive uropathy, as these were either unchecked or not marked on the assessment form. As a result, the baseline care plan created at admission did not include any focus, goal, or intervention related to urinary catheter care. Interviews with staff revealed that the absence of documentation regarding the catheter in the admission assessment and lack of physician orders led to the omission of catheter care in the baseline care plan. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, but this was not followed in this case due to incomplete or inaccurate documentation and assessment.