Failure to Develop Comprehensive Care Plans for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included specific services, treatments, measurable objectives, and timelines for residents with indwelling catheters. For two residents reviewed, the care plans either lacked any mention of catheter care or did not include goals and interventions related to catheter management. One resident, who had an indwelling catheter for 14 months and a history of multiple urinary tract infections, expressed uncertainty about receiving scheduled catheter care after a recent urology appointment. Review of this resident's medical record showed only two care plan issues addressed, neither of which included catheter care, despite physician orders for monthly catheter changes. Another resident's care plan acknowledged the presence of a urinary catheter but omitted goals and interventions for catheter care, even though physician orders specified catheter care every shift and monthly changes. Staff interviews confirmed that the care plans were incomplete and did not reflect the necessary services for catheter management. Facility policy required that baseline and comprehensive care plans address all immediate and ongoing care needs, but this was not followed for the residents in question.