Failure to Include Indwelling Catheter and Pain Management in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in deficiencies related to the omission of critical care needs. For one resident with a diagnosis of benign prostatic hyperplasia and an indwelling urinary catheter, the care plan did not document the presence or care requirements for the catheter. This omission was confirmed through record review and interviews with facility staff, including the Registered Nurse Supervisor, Director of Nursing, and Infection Preventionist, all of whom acknowledged that the catheter should have been included in the care plan to guide staff in providing appropriate care. For another resident with functional quadriplegia, multiple sclerosis, and chronic pain triggered by touch or movement, the care plan failed to address the resident's extreme pain and spasms during repositioning. Although the resident and multiple staff members reported significant pain and frequent refusal of repositioning due to discomfort, the care plan only referenced general skin impairment and pressure ulcer prevention without specific interventions for pain management during movement. The Assistant Director of Nurses attributed the lack of detail to issues with the care plan system following a facility acquisition, and the Director of Nursing confirmed the absence of pain-specific information in the care plan.