Failure to Revise Care Plan for Cardiac Monitor, Urinary Retention, and Rectal Bleeding
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was revised to reflect specific care needs for one sampled resident following admission from an acute care hospital. Facility policy titled “Comprehensive Care Plans-Timing” (revised 1/2025) required that each resident have a person-centered, comprehensive care plan developed, reviewed, and revised by the interdisciplinary team, with involvement of the resident and/or representative. For this resident, admitted in January 2026 and discharged in February 2026, review of the January 2026 plan of care showed no care plan problem addressing the presence of a Zio patch, a wearable cardiac monitor that was documented as present on admission in a Wound Weekly Monitoring Assessment dated 1/15/16 and referenced in the Discharge to SNF Summary and Transfer Order dated 1/14/26 as a cardiac monitor requiring follow-up for atrial fibrillation. The same resident’s January 2026 plan of care also lacked care plan problems for urinary retention and rectal bleeding, despite these conditions being identified and ordered for monitoring and intervention. The Discharge to SNF Summary and Transfer Order dated 1/14/26 documented urinary retention as a reason for the acute care hospitalization, and an Order Summary Report dated 1/15/26 included a physician’s order for PVR checks every six hours for three days with in-and-out catheterization if PVR exceeded 250 cc and MD notification if two or more consecutive catheterizations were required. Additionally, an Order Summary Report dated 1/17/26 contained a physician’s order to monitor signs and symptoms of rectal bleeding, yet no corresponding care plan problem was initiated. During interviews, RN 1 confirmed the Zio patch was present on admission and agreed it should have been care planned, and the ADON verified that care plans for urinary retention and rectal bleeding were absent and should have been revised to reflect these problems.
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