Inaccurate Diagnosis Documented in Catheter Care Plan
Penalty
Summary
The facility failed to ensure the accuracy of the medical record and care plan for one sampled resident when an incorrect diagnosis was documented. The resident was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, unspecified urinary incontinence, and urinary retention, and had an indwelling Foley catheter in place per physician orders and history and physical documentation. Review of the physician documentation and diagnoses showed no evidence that the resident had a diagnosis of neurogenic bladder. Despite the absence of this diagnosis in the medical record, the resident’s care plan documented that the resident had an indwelling catheter related to neurogenic bladder, BPH, and urinary retention. During interview and concurrent record review, the MDS Supervisor stated that an MDS nurse had completed the care plan, confirmed that the resident did not have neurogenic bladder, and acknowledged that this diagnosis should not have been included. In a separate interview, the DON also confirmed that the resident did not have a diagnosis of neurogenic bladder and that its inclusion in the care plan was incorrect, stating the facility was responsible for ensuring the accuracy of residents’ medical records.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.