Failure to Include Indwelling Catheter in Care Plan
Penalty
Summary
The facility failed to include the use of an indwelling urinary catheter on the care plan for a resident who had a history of benign prostatic hyperplasia (BPH), a recent urinary tract infection (UTI), and overflow incontinence. The resident was admitted with an indwelling catheter, as documented in the admission Minimum Data Set (MDS) and physician orders, which specified the catheter was to be changed every 30 days for BPH and overflow incontinence. Despite these documented needs, the care plan initiated and later revised for the resident did not address the presence of the indwelling catheter or provide any interventions or directions for its care. Observation confirmed the resident had an indwelling catheter in use, with the tubing and drainage bag stored under the wheelchair and urine visible in the tubing. Staff interviews further verified that the resident had the catheter since admission for the stated medical reasons. The facility's own policy requires comprehensive, person-centered care plans that include measurable objectives and services to meet residents' needs, but this was not followed in the case of the resident with the indwelling catheter.