Failure to Include Urinary Catheter Management in Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a urinary catheter included management and monitoring of the catheter. The resident, who had intact cognition and required assistance with all activities of daily living, was admitted with a diagnosis of benign prostatic hyperplasia and had a Foley catheter in place as ordered in the electronic health record. However, review of the care plan revealed that it did not address the use of the Foley catheter or include monitoring for side effects related to the catheter. Interviews with facility staff confirmed that the catheter was not included in the care plan upon admission, and that it should have been documented to ensure appropriate monitoring for signs and symptoms of infection, urine output, and other catheter-related care. The facility's policy required that care plans be comprehensive, current, and updated as the resident's care needs changed, but this was not followed in the case of the resident with the urinary catheter.