Failure to Timely Update Care Plan After Catheter Removal and Wound Resolution
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by an interdisciplinary team for one resident. Specifically, the care plan was not updated to reflect the removal of a urinary catheter, which had an order for removal, nor was it revised when a pressure ulcer wound resolved and the related order was discontinued. Documentation showed that the resident's care plan continued to list an indwelling catheter and an active pressure ulcer after both had been resolved or removed, as confirmed by medical records, medication administration records, and staff interviews. Multiple staff members, including nurses and certified nursing assistants, confirmed that the resident no longer had a catheter or an active pressure ulcer, but the care plan was not updated until after surveyor intervention. The resident involved was an older male with a history of schizophrenia and moderate cognitive impairment. Medical records indicated that the Foley catheter was removed and the pressure ulcer had healed, yet the care plan still reflected these resolved issues. Staff interviews revealed confusion and lack of clarity regarding responsibility for updating care plans, with various staff members indicating that the DON, ADON, or wound care nurse might be responsible. The facility's policy required the interdisciplinary team to review and revise care plans after each assessment, but this was not followed in this case.