F0656

D

Failure to Develop Care Plan for Resident With Indwelling Foley Catheter

Easton, Maryland Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to develop and implement a care plan addressing a resident’s specific needs related to an indwelling Foley catheter. The resident had a physician’s order for a Foley catheter for urinary retention dated 1/3/26, and the quarterly MDS with an assessment reference date of 1/6/26 documented indwelling catheter use in Section H0100A. The Treatment Administration Records for January, February, and March 2026 also documented ongoing use of an indwelling Foley catheter. Despite these documented orders and assessments, review of the care plan section of the resident’s medical record did not reveal any care plan related to the Foley catheter.

On 3/11/26 at 12:55 PM, surveyors observed the resident lying in bed with a Foley catheter drainage bag containing urine hanging on the left side of the bed and visible from the hallway. During an interview at 1:37 PM, the MDS Coordinator stated that the nursing team was responsible for creating and implementing care plans. Later that afternoon, the DON and the Nursing Home Administrator were informed of the finding that no care plan had been developed for the resident’s indwelling Foley catheter, despite its documented use and the facility’s responsibility to ensure care is planned based on identified needs.