Failure to Update Care Plan After Catheter Discontinuation
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident who had a urinary catheter discontinued. The resident, an older female with multiple diagnoses including hypertension, major depressive disorder, morbid obesity, urinary retention, type 2 diabetes, intertrochanteric fracture, urinary tract infection, and cerebral infarction, was admitted with a catheter in place. Physician orders indicated the catheter was discontinued, and the most recent quarterly MDS assessment reflected that the resident no longer had a catheter and was always incontinent. However, the resident's care plan continued to include interventions related to catheter care and enhanced barrier precautions for catheter use, which were no longer applicable. Observations and interviews confirmed that the resident did not have a catheter at the time of the survey, and the resident herself stated that the catheter had been removed. The MDS Coordinator acknowledged that the care plan had not been updated to reflect the resident's current condition and attributed this to an oversight. Facility policy requires that care plans be reviewed and updated by the interdisciplinary team at least quarterly and as resident conditions change, but this was not done in this case.