Failure to Update Care Plan for Positioning Device and Indwelling Catheter
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan to include interventions for a right hand positioning device and an indwelling urinary catheter. The resident had diagnoses including right-sided hemiplegia and benign prostatic hyperplasia, and the Annual MDS documented intact cognition with a BIMS score of 13, right-sided impairment of upper and lower extremities, and total dependence on staff for all ADLs. The existing care plan, dated 09/06/24, addressed an ADL self-care deficit associated with cerebral infarction and total dependence for personal hygiene and oral care, but did not include any information or interventions related to the indwelling Foley catheter or the right hand positioning device. Physician orders dated 2/19/26 directed that the resident’s indwelling catheter be changed every four weeks or as needed, and observation showed the resident seated in a recliner with a carrot positioning device lying on the bedside table, indicating the device was in use but not reflected in the care plan. During interviews, a licensed nurse stated that any staff member could update care plans with interventions such as the positioning device and catheter, but she was unaware that this resident’s care plan lacked that information. An administrative nurse stated she expected all nursing staff to update care plans. The facility’s care plan policy, revised 2/3/25, required development of a person-centered plan of care that identifies needs, strengths, preferences, health status, and establishes goals and services to ensure the highest level of functioning, which was not fully implemented for this resident regarding the catheter and hand positioning device.
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