Failure to Develop and Provide Baseline Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and provide a baseline or comprehensive care plan within 48 hours of admission for a resident with an indwelling urinary catheter. According to the facility's policy, a baseline care plan must be created within 48 hours of admission and include essential healthcare information such as physician orders, initial goals, and specific care instructions. The policy also requires that a written summary of the baseline care plan be provided to the resident or their representative, with a signature obtained to verify receipt and a copy placed in the medical record. In this case, the resident was admitted with a diagnosis of neurogenic bladder and had an indwelling urinary catheter, as documented in the admission assessment and physician's orders. Despite these requirements, review of the resident's medical record showed no evidence that a baseline or comprehensive care plan addressing the use of the indwelling urinary catheter was developed within the required timeframe. The resident confirmed during an interview that they were not provided with, nor asked to sign, a summary of a baseline care plan. Consulting staff also verified that the care plan for the urinary catheter was not completed as required. This deficiency was identified for one resident out of a sample of seventeen.