Failure to Include Indwelling Urinary Catheter in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing an indwelling urinary catheter for one resident, as required to be completed within 7 days of the comprehensive assessment and prepared by an interdisciplinary team. The resident was admitted with urinary retention and had an indwelling urinary catheter documented on the admission MDS assessment. Physician orders dated 06/23/25 directed that the urinary catheter be maintained with catheter changes as needed, catheter bag changes as needed, catheter care every shift and as needed, placement of a stat lock to secure the catheter, and verification of catheter placement every shift. Treatment Administration Records for June and July 2025 showed the resident had a urinary catheter and received daily catheter care. However, review of the comprehensive care plan dated 07/03/25 revealed no mention of the urinary catheter. During an interview, the MDS Coordinator acknowledged that the urinary catheter was not included on the care plan and stated that at the time of the resident’s admission the facility was undergoing a company change and electronic medical record upgrade, and it was possible the system did not accept her care plan input. The Administrator stated she expected all residents to have an accurate and complete comprehensive care plan reflecting their clinical condition, medications, and care needs.
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