Failure to Update Comprehensive Care Plan for Resident with Catheter and Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for one resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, to reflect the resident's current condition. Specifically, the care plan did not include the resident's use of an indwelling urinary catheter or the presence of a stage 4 pressure ulcer to the sacrum, despite these conditions being documented in the resident's medical records and orders. The resident had diagnoses including severe protein-calorie malnutrition, heart failure, respiratory failure, dysphasia, kidney failure, and urinary retention, and was cognitively intact. Orders for catheter care and wound care were present and active, but these interventions were not reflected in the care plan. Interviews with facility staff revealed that the MDS Coordinator was responsible for auditing and updating care plans, and the DON acknowledged that the care plan should have included the resident's wound and catheter. The omission was attributed to the care plan not being updated after the admission MDS assessment, which had triggered the need for these interventions. Facility policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan within seven days of the comprehensive assessment, but this was not followed for the resident in question.