Failure to Individualize Care Plans for Residents on IV Antibiotics and Anticoagulants
Penalty
Summary
The facility failed to develop comprehensive care plans that included specific and individualized treatment for two residents who were receiving intravenous antibiotics and anticoagulants. For one resident, admission orders included a PICC line for administering Vancomycin for a left hip infection. Observations confirmed the presence of the PICC line, and the Medication Administration Record (MAR) showed regular administration of the antibiotic and IV flushes. However, there was no documented evidence in the care plan regarding the PICC line or the antibiotic treatment. An interview with the Assistant Director of Nursing confirmed the omission and acknowledged that the care plan should have been individualized to include these treatments. Similarly, another resident was receiving Xarelto, an anticoagulant, as per admission orders. The MAR confirmed daily administration of the medication, but the care plan did not document the anticoagulant treatment. The Assistant Director of Nursing confirmed that the care plan was not individualized to include the resident's anticoagulant medication, which was a necessary component of the resident's care plan.
Plan Of Correction
1. Residents 37 and 293 have been discharged from the facility. 2. Any newly admitted resident has the potential to have an incorrect care plan. 3. The clinical team will review new admissions, including the initial care plan the next business day after admission to ensure no medications are missed on the admission care plan. Clinical team has been educated on this altered process. 4. Random audits of new admissions will be done weekly x 4 and then monthly x2 to ensure that medications are included in the initial care plan. These audits will be reported to the Quality Assurance team for review. Director of Nursing or designee will monitor.