F0656

D

Failure to Care Plan and Obtain Order for Enhanced Barrier Precautions for Catheterized Resident

Raymondville, Texas Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident requiring enhanced barrier precautions (EBP). The resident was an older male with dementia, bladder-neck obstruction, urinary incontinence, and a cognitive communication deficit, admitted with an indwelling/foley catheter. His quarterly MDS showed a BIMS score of 09, indicating moderately impaired cognition, and documented the presence of the indwelling catheter. However, review of his quarterly care plan dated 12/26/25 showed that the need for EBP related to his indwelling/foley catheter was not included, despite facility policy requiring comprehensive care plans to address identified medical, nursing, and psychosocial needs.

During observation, the resident’s room displayed EBP signage, and gowns and gloves were available outside the room with a trash can inside near the exit, and the resident was seen in bed with an indwelling/foley catheter and a privacy cover on the drainage bag. In interviews, the MDS RN confirmed that the resident’s catheter required EBP and acknowledged that EBP was neither care planned nor supported by a physician’s order in the electronic medical record. The DON stated that facility protocol required an order for EBP and that EBP must be included in the care plan so staff would know what precautions to take during high-contact care. The DON also reported that the facility did not have a policy related to physician’s orders, and the existing Comprehensive Care Plans policy required services to be described to meet the resident’s highest practicable well-being, which was not done in this case for EBP.