Failure to Add Ordered Catheter Irrigation to Resident Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to include physician-ordered suprapubic catheter irrigation in a resident’s comprehensive care plan. The facility’s care plan policy, revised 10/21/2025, requires that the comprehensive care plan describe the services to be furnished to attain or maintain the resident’s highest practicable well-being. Review of the resident’s care plan dated 12/10/2025 showed a problem of an indwelling catheter related to neurogenic bladder, BPH, and urinary retention, with interventions such as changing the catheter at the urologist’s office per spouse preference, administering cranberry supplement for UTI prophylaxis as ordered, keeping catheter tubing free of kinks, maintaining the drainage bag below bladder level, preventing tension on the urinary meatus, and providing catheter care per policy. However, there was no mention of irrigating the urinary catheter. Record review showed a physician’s order for the resident to have the suprapubic catheter irrigated with 50 cc of normal saline every shift, which was not reflected in the care plan. In interviews, the MDS Coordinator stated she communicated with the IDT in morning meetings about changes to orders or residents’ status and indicated she should have been informed of the urinary catheter irrigation order so she or a unit nurse could add it to the care plan. The DON stated that expectations were for the Charge Nurse, Unit Manager, or MDS Coordinator to make care plan changes as soon as they were ordered. The Administrator reported that the MDS department had stated in a morning meeting that they were caught up with MDSs and care plans, but that this was not accurate.
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