Failure to Include Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had an indwelling catheter. Upon review, it was found that the resident was admitted and readmitted with multiple diagnoses, including dysphagia, dementia, obstructive uropathy, and reflux uropathy, and had an order for an indwelling catheter. The resident's assessments and medical records consistently documented the presence of the catheter and the need for substantial assistance with activities of daily living due to severely impaired cognitive skills. Despite this, the baseline care plan created at admission did not include any information regarding the resident's indwelling catheter. Interviews with facility staff, including the MDS nurse and the Assistant Director of Nursing, confirmed that the baseline care plan was incomplete and did not address the catheter, contrary to facility policy and procedure. This omission meant that the resident's immediate care needs related to the indwelling catheter were not documented in the baseline care plan.