Failure to Develop Baseline Care Plan for Nephrostomy Tubes
Penalty
Summary
Nursing staff failed to develop and implement a baseline care plan addressing the immediate care and treatment needs for a resident with bilateral nephrostomy tubes within 48 hours of admission. The facility's policy requires that a baseline admission care plan be created within 48 hours to provide effective, person-centered care, including all physician orders and specific interventions for medical devices such as nephrostomy tubes. However, upon review of the resident's records, there was no documentation of a baseline care plan that included goals, interventions, or maintenance instructions for the nephrostomy tubes. The resident in question had a complex medical history, including urothelial carcinoma, status post cystectomy, hydronephrosis, an ileal conduit/urostomy, and bilateral nephrostomy tubes. Interviews with facility staff, including the Unit Manager and DON, confirmed that the required baseline care plan for the nephrostomy tubes was not developed or documented as per facility policy. This omission was identified during a review of the resident's admission records and confirmed through staff interviews.