Failure to Develop Care Plan for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing a resident's suprapubic indwelling catheter. The facility's policy required each resident to have a person-centered care plan identifying problems, needs, strengths, preferences, goals, and how the interdisciplinary team would provide care, with review and revision at least quarterly and with MDS assessments. Resident #7 was admitted with multiple diagnoses including Type 2 diabetes mellitus with diabetic mononeuropathy, UTI, anxiety, cellulitis of both lower limbs, edema, venous insufficiency, and neuromuscular dysfunction of the bladder. The resident had intact cognition, as evidenced by a BIMS score of 14 on the quarterly MDS. Physician orders included a urology consult for suprapubic catheter placement, suprapubic catheter care with soap and water every shift, and monthly suprapubic catheter changes with PRN changes for leakage or occlusion. Despite these orders and the presence of the suprapubic catheter, review of the resident's care plan showed no documentation or evidence that the catheter was addressed in the care plan. During observation, the resident was seen sitting in a wheelchair in the hallway with the suprapubic indwelling catheter hanging on the right wheelchair arm with a privacy cover. In an interview, the care plan coordinator, who was responsible for developing and updating all resident care plans and stated she reviewed and revised care plans quarterly and with changes in condition, confirmed that the care plan for this resident did not address the suprapubic catheter but acknowledged that it should have been included.
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