Failure to Develop and Implement Comprehensive Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, specifically omitting care planning for the resident's Foley catheter. The resident, a male with quadriplegia, neurogenic bladder, and a Stage 2 pressure ulcer, was dependent on staff for toileting hygiene and had a Foley catheter in place throughout the assessment period. Despite these needs, the care plan did not address the Foley catheter, and there were no physician orders related to its care. Nurse Practitioner notes indicated the need for a catheter securement device, but this was not reflected in the care plan or orders. Interviews with nursing staff revealed a lack of clarity regarding the care and documentation of the Foley catheter, with staff relying on general knowledge rather than specific care plans or orders. The Regional Compliance Nurse acknowledged that the interdisciplinary team was responsible for updating care plans and that the omission of the Foley catheter from the care plan and orders was an oversight from admission. The facility's policy required comprehensive care plans to address all medical needs, but this was not followed in this case.