Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop, implement, and individualize a comprehensive care plan for a resident with an indwelling urinary catheter. Despite the facility's policy requiring a person-centered care plan to be developed within seven days of the comprehensive Minimum Data Set (MDS) assessment, and the resident's MDS assessment triggering a care area for urinary catheter, no care plan addressing the catheter was found in the resident's records. The resident, who was cognitively intact and had a diagnosis of uninhibited neurogenic bladder, had documented physician orders for Foley catheter use and care, as well as nursing assessments confirming the presence of the catheter. During the survey, the resident was observed with a urinary catheter in place, and a review of the care plans confirmed the absence of a care plan specific to the indwelling catheter. Consulting staff acknowledged that a care plan should have been developed for this triggered care area but was not. The deficiency was identified through observation, interview, and record review, demonstrating a failure to meet the facility's own policy and regulatory requirements for comprehensive care planning.