Failure to Update Care Plan for Resident with New Indwelling Catheter
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident who was readmitted with a new indwelling catheter. Upon review, it was found that the care plan did not reflect the presence of the catheter or include goals and interventions necessary for its care. The resident had a history of chronic obstructive pulmonary disease, acute respiratory failure, and unspecified dementia, and required maximal assistance with activities of daily living. The Minimum Data Set indicated severely impaired cognitive functioning, and the resident was unable to make medical decisions independently. During an interview and record review, a registered nurse confirmed that the care plan was not updated upon the resident's readmission, despite the facility's policy requiring care plan revisions after significant changes in condition or readmission from a hospital stay. The lack of an updated care plan meant that staff did not have documented guidance to monitor or address the resident's catheter care, which was necessary to meet the resident's physical and functional needs as outlined in the facility's policy.