Failure to Develop Baseline Care Plans for Mental Health and Foley Catheter Care
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents with specific care needs. For one resident with diagnoses of bipolar disorder, depression, anxiety disorder, and dementia, the baseline care plan did not address the care, treatment, or interventions required for the resident's mental health conditions, despite physician orders for medications to manage these diagnoses. The Director of Nursing confirmed that the care plan omitted these mental health diagnoses and acknowledged that including them would be beneficial for understanding and meeting the resident's care needs. For another resident admitted with urinary retention, benign prostatic hyperplasia, and chronic heart failure, the baseline care plan failed to specify the type of catheter in use and did not include appropriate interventions for Foley catheter care. Although the resident had a physician's order for an indwelling catheter and the Minimum Data Set documented its presence, the care plan used a placeholder instead of specifying the catheter type and lacked details such as type and size, care instructions, and monitoring for complications. Both the Director of Nursing and the Regional Director of Clinical Services confirmed these omissions and stated that the care plan should have included this critical information.