F0657

D

Failure to Revise Care Plan and Obtain EBP Order for Resident With Indwelling Catheter

Los Angeles, California Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to timely and accurately revise the comprehensive care plan and obtain appropriate orders related to infection control precautions for one resident. The resident was admitted with diagnoses including diabetes mellitus, protein calorie malnutrition, and reduced mobility, and had moderately impaired cognition per the MDS. The MDS also documented that the resident had an indwelling catheter and was dependent on staff for toileting hygiene, bathing, dressing, and required assistance with oral hygiene and eating. The facility’s care plan, initiated on 7/3/24, indicated the resident was on Enhanced Barrier Precautions (EBP) due to a wound but did not reflect that the resident also had an indwelling catheter, despite this being documented elsewhere in the record.

During observation, the resident was seen lying in bed with an indwelling catheter hanging on the right side of the bed. In a concurrent interview and record review with the DON, it was confirmed that the resident should be on EBP because of both wounds and the indwelling catheter, and that there was no physician order in place to initiate EBP for this resident. The DON acknowledged that the care plan should be revised and that a physician order was needed to place the resident on EBP. Facility policies stated that care plans must be reviewed and revised at least quarterly or more often as the resident’s condition warrants, and that EBP are indicated for residents with wounds and/or indwelling medical devices even if they are not known to be infected or colonized with MDROs. The failure to revise the care plan to include the indwelling catheter and to obtain a physician order for EBP had the potential to spread infection to other residents, staff, and visitors.