Failure to Accurately Individualize Care Plan for Resident With Hematuria
Penalty
Summary
The facility failed to develop and implement an accurate, person-centered care plan for a resident who experienced hematuria. The resident was admitted with diagnoses including unspecified encephalopathy, unspecified dementia, and diabetes mellitus, and was documented as lacking capacity to make decisions and having severely impaired cognitive skills. The MDS indicated the resident was always incontinent of bowel and bladder. On one date, a Change of Condition note documented that a CNA reported to an LVN that the resident had blood-tinged urine in their diaper on two occasions during the early morning. A physician order was obtained for a urinalysis with culture and sensitivity, with permission to perform straight catheterization for urine collection if a clean catch specimen could not be obtained. The resident’s care plan, initiated in response to the hematuria, documented interventions related to monitoring and caring for an indwelling Foley catheter, including monitoring the catheter and changing it or the bag as ordered, providing Foley catheter care every shift, and maintaining proper alignment of the Foley catheter. However, interview and record review confirmed that the resident did not have an indwelling catheter and that urine for the ordered tests was obtained via straight catheterization. The DON acknowledged that the care plan was not individualized or accurate, stating that the resident never had an indwelling catheter and that the care plan should have reflected the use of straight catheterization and been consistent with the resident’s actual needs and orders, in contrast to the facility’s policy requiring individualized care plans.
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.