Failure to Develop Comprehensive Care Plan for Resident with Catheter and Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs. Specifically, the care plan did not address the presence of an indwelling urinary catheter or a fractured left radius, despite these conditions being documented in the resident's medical record and Minimum Data Set (MDS) assessment. The resident's diagnoses included a left arm fracture, obstructive and reflux uropathy, and other chronic conditions, and the MDS indicated the use of an indwelling catheter and a recent fracture, both of which triggered care area assessments. Observations confirmed the resident had an indwelling urinary catheter and her left arm was immobilized in a cast and sling. Interviews with the resident revealed she experienced pain in her left arm, which was managed with medication, and she denied numbness or tingling. Despite these findings, the comprehensive care plan reviewed did not include interventions or objectives related to the catheter or the arm fracture. Interviews with facility staff, including the DON, MDSC, and administrator, revealed that responsibility for care plan creation and monitoring was shared among the interdisciplinary team. Staff acknowledged that issues could be missed due to miscommunication and that care plans were expected to be accurate and updated promptly. The facility's policy required comprehensive, person-centered care plans based on assessments, but in this case, the care plan did not reflect the resident's current needs as identified in the assessment and observations.