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F0656
D

Failure to Develop Timely Care Plan for Catheter Use

Baltimore, Maryland Survey Completed on 07-24-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to develop a care plan to address a resident's use of an indwelling urinary catheter, despite a physician's order for catheterization and documentation in the Minimum Data Set (MDS) assessments indicating the presence of a catheter. The Care Area Assessment (CAA) from the resident's Admission MDS noted that the Interdisciplinary Team (IDT) agreed to create a care plan for the catheter, but a review of the clinical record revealed that no such care plan was in place for approximately three months following admission. During the survey, the Director of Nursing (DON) was interviewed and initially did not provide evidence of a care plan addressing catheter use. When a care plan was later produced, it was found to have been initiated only after a significant delay, well after the resident's admission and the original physician's order. The DON acknowledged that the resident went without a required care plan for catheter use during this period.

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