Failure to Implement Care Plan Documentation for Nutrition and Catheter Output
Penalty
Summary
Surveyors identified that the facility did not implement existing care plan interventions for monitoring and documenting nutritional intake and urinary catheter output. One resident with Alzheimer's disease, dysphagia, and protein-calorie malnutrition had a care plan directing staff to monitor and record meal consumption at every meal due to a history of weight loss and dependence on staff for eating. However, food intake documentation was missing for multiple meals on several dates, including no dinner intake recorded on specific days and no breakfast and lunch intake recorded on others. The DON stated the resident’s food consumption was supposed to be documented after each meal. Two residents with indwelling urinary catheters also had care plans requiring intake and output monitoring and documentation each shift, but staff failed to document urinary output as directed. One resident with vascular dementia and neurogenic bladder had a Foley catheter with orders and a care plan intervention to monitor and document intake and output per facility policy, yet there were multiple shifts across day, evening, and night with no urinary output recorded. Another resident with obstructive and reflux uropathy, neuromuscular bladder dysfunction, and a suprapubic catheter had a care plan intervention to record urinary output every shift, but there was no documented urinary output for the prior 30 days. The DON and Nurse Consultant confirmed that output should have been documented every shift for one resident and that the care plan intervention for the other should have been discontinued, indicating the care plans were not accurately implemented or updated.
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