Failure to Develop Individualized Care Plans for Residents with Opioid Use and Indwelling Foley Catheter
Penalty
Summary
The facility failed to develop individualized care plans for two residents with specific clinical needs. For one resident who was prescribed oxycodone 10 mg orally every 6 hours as needed for pain, there was no care plan addressing the use of this opioid medication. Record review showed that the resident received oxycodone twice daily for 24 days in August, yet no care plan or monitoring interventions related to opioid administration were documented. The DON confirmed that a care plan should have been in place for this medication order. In another case, a resident admitted with an indwelling foley catheter did not have a care plan that included focus areas, goals, or interventions for catheter management. Although the baseline care plan and admission MDS documented the presence of the catheter, the comprehensive care plan lacked any mention of it. This omission was confirmed by both the director of social work and the DON during interviews.