Failure to Develop Comprehensive Care Plan for Urinary Retention and Catheter Use
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address a resident's urinary retention and use of a urinary catheter. The resident, who had a history of recurrent urinary tract infections (UTIs), was admitted without a urinary catheter but began experiencing difficulty urinating after admission. As a result, a urinary catheter was ordered and inserted, and the resident was placed on Flomax for urinary retention. Voiding trials were attempted but were unsuccessful, and a urology consult was ordered for ongoing urinary retention and chronic UTIs. Despite these interventions and changes in the resident's condition, there was no documented evidence that the care plan was updated to reflect the resident's urinary retention, catheter use, or the interventions being implemented, such as voiding trials. Interviews with staff confirmed that the care plan had not been updated to address these specific care needs until after the issue was identified by surveyors. The deficiency was identified through record review and staff interviews, which revealed a lack of timely and comprehensive care planning for the resident's urinary issues.