Failure to Document Suprapubic Catheters on Baseline Care Plans
Penalty
Summary
The facility failed to include necessary healthcare information on the baseline care plans for two residents within 48 hours of admission. Specifically, both residents had suprapubic catheters in place as documented in their hospital discharge summaries, licensed nurse assessments, and other medical records. However, this critical information was omitted from their baseline care plans, which are intended to guide caregivers in providing effective and person-centered care immediately upon admission. For the first resident, who had multiple diagnoses including a stage 3 pressure ulcer, MRSA, and neurogenic bladder, the presence of a suprapubic catheter was not documented on the baseline care plan despite being noted in the hospital discharge summary. Similarly, the second resident, admitted after joint replacement surgery and with chronic kidney disease and an overactive bladder, also had a suprapubic catheter that was not included in the baseline care plan, even though it was documented in the hospital discharge instructions, nurse assessment, and MDS. The Director of Nursing confirmed that the omission of the suprapubic catheter from both residents' baseline care plans was an oversight.