Failure to Develop Comprehensive Care Plan for Resident With Suprapubic Catheter
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for one resident with a suprapubic catheter. Facility policy required a comprehensive care plan with measurable objectives and timeframes to be developed within seven days after completion of the comprehensive MDS, considering all triggered Care Area Assessments and other identified needs. For this resident, physician orders dated at admission directed suprapubic catheter changes as needed, monitoring of catheter output every shift, and catheter care every shift, and the treatment administration record showed ongoing suprapubic catheter care throughout the month. However, the comprehensive care plan initiated shortly after admission contained only an activities focus and did not include any focus, goals, or interventions related to catheter care or other ADLs. The resident’s admission assessment documented severe cognitive impairment with a BIMS score of 3, diagnoses of obstructive uropathy and non-Alzheimer dementia, and the presence of a catheter, with urinary continence not rated due to catheter use. The assessment also showed the resident required varying levels of assistance for eating, bathing, dressing, and was dependent for bed transfers, but these needs were not reflected in the comprehensive care plan. A resident representative confirmed the resident had a catheter upon admission and throughout the stay. A CNA reported there was no documentation directing catheter care, although they stated they checked and provided care for all catheters every two hours. The DON and the MDS coordinator both acknowledged on review that the comprehensive care plan for this resident was incomplete, containing only an activities focus and omitting catheter care and ADLs, and that the comprehensive care plan had been missed.
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