Failure to Revise Care Plan After Catheter Re-Insertion
Penalty
Summary
A deficiency occurred when the facility failed to revise the care plan for a resident after a significant change in condition. The resident, who had diagnoses including Alzheimer's disease, dementia, type 2 diabetes mellitus, major depressive disorder, chronic kidney disease stage 3, and benign prostatic hyperplasia, was admitted on hospice care and initially had a Foley catheter in place. The care plan for the indwelling Foley catheter was resolved after the catheter was removed. However, following an episode of urinary retention, the resident's catheter was re-inserted, but the care plan was not updated or re-initiated to reflect this change. Surveyor observations and record reviews confirmed that the resident continued to have a catheter in place, as evidenced by direct observation and progress notes documenting the re-insertion. Interviews with facility staff, including the registered nurse unit manager and the director of nursing, revealed that care plans are typically reviewed during daily interdisciplinary team meetings, especially when a resident experiences a change in status. Despite this process, the care plan for the resident was not revised after the catheter was re-inserted, and staff acknowledged that this oversight should have been addressed at the time of the status change.