Failure to Revise Care Plan After Discontinuation of Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing assessment and to revise and update an individualized comprehensive care plan according to a resident’s current condition and treatments. A resident admitted with diagnoses including cerebral atherosclerosis, CKD stage 4, type 2 diabetes mellitus, and hemiplegia/hemiparesis following cerebral infarction was observed lying in bed, dependent with ADLs and transfers, incontinent of bowel and bladder, awake, responsive, but confused. Observation and record review showed that the resident’s active physician orders did not include an indwelling urinary catheter, and a significant change MDS assessment documented that the resident did not use an indwelling catheter and was incontinent of bladder. Despite this, the comprehensive care plan still indicated that the resident required the use of an indwelling urinary catheter, with a target goal date months after the catheter had been discontinued. Staff interview revealed that the catheter had been discontinued on a specific date, but the Resident Coordinator, who stated she updates care plans for changes in condition and plan of care, was not aware of the discontinuation and had not updated the care plan. She acknowledged that she had completed the significant change MDS assessment but had not revised the care plan to reflect the discontinued catheter, contrary to the facility’s policy that requires ongoing assessment and care plan revision based on changes in condition, treatments, and goals.
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