Failure to Develop and Implement Baseline Care Plan for New Admission with Foley Catheter and UTI
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan within 48 hours of admission that included all necessary instructions for effective, person-centered care for a newly admitted resident. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, and Wernicke's encephalopathy, was admitted with a Foley catheter and an active urinary tract infection (UTI) requiring antibiotics. Despite hospital discharge records and multiple nursing notes indicating the presence of a Foley catheter and ongoing antibiotic treatment, the facility's care plan did not specifically address the resident's catheter care or current UTI and antibiotic use. The medical record review revealed inconsistencies and omissions regarding the resident's catheter status and care. The Minimum Data Set (MDS) did not reflect the presence of an indwelling catheter, and there were no physician orders for catheter care or monitoring. Nursing documentation failed to consistently record skilled assessments or urine output measurements related to the Foley catheter. Although some care plan interventions referenced catheter care if a catheter was in place, the plan lacked specificity and did not incorporate the hospital's discharge instructions or the resident's current infection and antibiotic regimen. Interviews with facility staff, including nurses, the administrator, and the DON, confirmed that the care plan was not individualized to the resident's needs and did not include essential information from the hospital discharge summary. Staff acknowledged that the lack of a resident-centered care plan and failure to document and implement catheter care could result in unmet care needs. The resident was ultimately hospitalized with a diagnosis of sepsis, and the facility's failure to provide a comprehensive, individualized care plan within the required timeframe was identified as the root cause of the deficiency.