Failure to Develop Resident-Centered Care Plan for Intermittent Catheterization
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident with a flaccid neuropathic bladder and a thoracic vertebra fracture. The resident was admitted with a history of performing intermittent catheterization at home, but the care plan did not include specific interventions or mention intermittent catheterization. Interviews with nursing staff and record reviews confirmed that the care plan lacked necessary details to guide staff in providing appropriate care for the resident's condition. The resident's Minimum Data Set (MDS) assessment indicated impaired cognition, further emphasizing the need for a comprehensive and clear care plan. Staff interviews revealed that the omission of intermittent catheterization from the care plan led to confusion among staff and inadequate communication regarding the resident's care needs. The Assistant Director of Nursing and licensed nurses acknowledged the importance of a detailed care plan for ensuring consistent care and preventing confusion. The resident was eventually transferred to an acute hospital due to altered mentation, which included an inability to self-catheterize, highlighting the impact of the incomplete care plan.