Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had an indwelling urinary catheter from late January to early April. Despite the resident's complex medical history, including chronic kidney disease stage 4, type 2 diabetes mellitus, hypertensive heart disease with heart failure, and a recent urinary tract infection, the comprehensive care plan did not address the presence or management of the indwelling catheter. The baseline care plan and MDS assessment noted the catheter, but this information was not carried over to the comprehensive care plan, leaving a gap in documented interventions and measurable objectives related to catheter care. Physician orders during the period specified detailed specific catheter care, including flushing, monitoring output, and changing the catheter as needed. Nursing progress notes confirmed the presence and management of the catheter, and staff interviews revealed that the catheter was in place due to urinary retention. However, the comprehensive care plan, which is intended to guide all staff in providing consistent and appropriate care, did not include any care area or interventions related to the catheter. This omission was confirmed by the MDS Nurse, who acknowledged that the catheter was not addressed in the comprehensive care plan and that this information should have been included to inform staff. Interviews with facility leadership, including the DON and the MDS Nurse, confirmed that the catheter was not included in the care plan and that this was an oversight. The facility's own policy requires that comprehensive care plans include measurable objectives and timeframes for all identified needs, and that care plans be updated with any significant change in condition or upon readmission. The lack of a care plan addressing the indwelling catheter meant that staff did not have documented guidance on catheter care, which could have led to inconsistent care practices.