Failure to Develop and Implement Comprehensive Care Plans for Catheter Care and Scheduled Bathing
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, as required by policy. One resident with an indwelling catheter did not have a care plan addressing the use and care of the catheter, despite having a physician's order for catheter care and a diagnosis of mechanical complication of a urinary catheter. The resident's comprehensive MDS assessment also documented the presence of the catheter, but no corresponding care plan was created within the required timeframe. Additionally, two residents with scheduled bathing and shower interventions in their care plans did not receive these services as planned. Documentation showed that one resident received only one bath during the month, missing twelve scheduled showers, while another resident missed seven scheduled showers. Both residents expressed dissatisfaction with the frequency of their baths and showers, and the DON acknowledged ongoing issues with staff following care plans for bathing due to CNA staffing challenges. Interviews with staff and administration confirmed awareness of the missed care and the lack of a care plan for the resident with a catheter.