Failure to Develop Baseline Care Plan for Urinary Catheter Use
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with a Foley catheter. Upon review of the resident's admission record, history and physical, and order summary report, it was found that while there was an order for the Foley catheter, there was no documented indication for its use. Additionally, there was no baseline care plan created to address the use of the urinary catheter, as confirmed by both the LVN and the Director of Nursing during interviews. The lack of a baseline care plan meant that essential, person-centered care instructions for the safe use of the catheter were not provided to staff. The resident in question was admitted with diagnoses including muscle weakness, difficulty walking, and acute kidney failure, and was observed to have a Foley catheter in place. Despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, this was not done for the resident's urinary catheter. The deficiency was identified through observation, interviews with staff, and review of the resident's records, which confirmed the absence of both an indication for the catheter and a baseline care plan.