Failure to Develop Care Plan for Dislodged Nephrostomy Tube
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the needs of a resident who experienced a dislodged nephrostomy tube. According to the facility's policy, a person-centered care plan with measurable objectives and timetables should be developed and implemented for each resident, including after a change in condition. Medical record review showed that the resident, who had moderately impaired cognition, had a nephrostomy tube dislodged and was transferred to an acute care hospital for re-insertion. Upon return to the facility with the tube replaced, there was no evidence that a care plan was created to address the dislodged and replaced nephrostomy tube. Interviews with facility staff, including an LVN and the DON, confirmed that no care plan was developed for the resident's nephrostomy tube incident. The staff acknowledged that a care plan should have been initiated following the change in condition, including interventions such as transfer to the hospital and care of the nephrostomy tube site. The absence of a care plan meant the resident's specific needs related to the nephrostomy tube were not formally addressed in the care planning process.