F0656

D

Failure to Maintain Current, Resident-Specific Care Plans for Skin and Catheter Management

Saginaw, Michigan Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain up-to-date, resident-specific care plans with measurable interventions, as required by its comprehensive care plan policy. For one resident with sepsis, multiple fractures, non‑weight‑bearing status, and a facility-acquired pressure ulcer on the right foot, physician orders dated 3/10/26 directed use of an air cast and specific cleansing and dressing of a newly acquired pressure ulcer on the right inner ankle. The resident’s skin care plan, initially dated 2/25/26 and updated 3/10/26, listed an actual Stage 1 pressure area to the inner right ankle and right bunion and small red areas to the right small toe, but contained no documented interventions addressing the newly developed pressure ulcer on the right inner ankle. During review of the care plans with the DON, the DON acknowledged that new interventions for the actual skin impairment should have been added to the skin care plan.

Another resident was admitted with a 16 French indwelling Foley catheter and milky discharge at the penile insertion site. Observations documented the catheter drainage bag and spout touching the floor, with the clear plastic Urometer and catheter bag repeatedly found resting on the floor and the tubing under the bed, and no privacy bag in place. A family member reported that the catheter had been hanging in this manner since admission and that no covering bag had been used. The ICP stated that catheter bags should not rest on the floor, that privacy bags should be used, and that staff are aware of this expectation, and also acknowledged that he had not rounded in this resident’s room. The facility’s indwelling catheter care policy requires inspection of catheter and tubing, use of a securement device, keeping the drainage bag below bladder level, ensuring the bag and tubing are not on the floor, and placing drainage bags in a privacy bag. The resident’s care plan, initiated on admission, did not include an indwelling catheter care plan until two days later, despite the catheter and drainage issues noted in progress notes.

A third resident had multiple medical diagnoses including chronic kidney disease, congestive heart failure, and pressure-induced deep tissue damage of the sacral region. The admission assessment documented two open areas with dressings on the left knee and scattered bruising. Observations over multiple days showed the resident in bed with heels resting on the footboard or flat on a standard mattress, without an air mattress, positioning devices, extra pillows for heel off‑loading, or devices to relieve pressure from the tailbone, despite the resident’s repeated reports that both heels were sore and painful and that she had a sore on her tailbone. A family member reported that staff did not assist with basic care and that the bathroom was dirty, and was later observed independently showering the resident without staff present. Review of the resident’s care plan, developed shortly after admission, identified potential/actual impairment to skin integrity related to fragile skin and actual open areas to the lower left extremity, with interventions focused on skin hygiene, moisture control, nail care, lotion use, and following facility skin treatment protocols, but no interventions for an air mattress, positioning devices, or a turning schedule, contrary to the facility’s policies on baseline skin assessment and comprehensive care planning.