Failure to Update Care Plan After Discontinuation of Indwelling Catheter
Penalty
Summary
The facility failed to revise the care plan for a resident following a significant change in their medical status. The resident, who had diagnoses including heart failure, malignant neoplasm of the pancreas, and anxiety, was admitted with an indwelling urinary catheter. The comprehensive care plan documented the presence of the catheter. However, after the resident was hospitalized and subsequently readmitted without the catheter, the care plan was not updated to reflect the discontinuation of the device. Observations on multiple dates confirmed that the resident no longer had an indwelling urinary catheter. Interviews with nursing staff and the Director of Nursing further verified that the care plan had not been revised to address the change in the resident's condition. This failure was identified through facility policy review, medical record review, direct observation, and staff interviews.