Failure to Develop and Implement Comprehensive Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling Foley catheter and leg band strap stabilizer. Despite the resident's medical history of acute kidney failure and neuromuscular dysfunction of the bladder, and being dependent on staff for all activities of daily living, the care plan did not address the presence of the Foley catheter or the need for securement. Multiple observations over several days confirmed that the resident's Foley catheter was not secured to his leg, and no securement device was in use, despite physician orders for catheter care and the use of a leg strap. Interviews with facility staff, including the Administrator, MDS Coordinator, ADON, and interim DON, revealed that the care plan was not updated to reflect the resident's current needs. Staff acknowledged that the care plan should have included the Foley catheter and its securement, and that comprehensive care plans were not being consistently completed or updated. The facility's policy required care plans to be developed and implemented within specific timeframes, but this was not followed for the resident in question.