Failure to Update Care Plan for Tuberculosis Diagnosis
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident R1, to reflect changes in care needs following a new tuberculosis diagnosis. The comprehensive care plan, which should have been revised by the interdisciplinary team after each assessment, did not include any interventions or specific care plans addressing the tuberculosis diagnosis. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan had not been updated to include special interventions related to care and isolation requirements. Resident R1 was admitted to the facility in late December 2024, and a review of their Minimum Data Set indicated that the Brief Interview for Mental Status was not recorded, suggesting severe cognitive impairment. In early January 2025, the facility was notified by a local hospital that Resident R1's tuberculosis test returned positive, prompting the facility to isolate the resident and notify relevant parties. However, the care plan dated December 30, 2024, did not reflect these significant changes in the resident's health status.
Plan Of Correction
1. Resident R1 care plan was updated to reflect active Tuberculosis diagnosis. 2. An audit of new diagnosis related to infectious disease will be completed going back 30 days to ensure appropriate care plans exist. 3. Professional nursing staff will be re-educated on updating care plans to reflect any new diagnosis obtained during their stay. 4. The DON/designee will complete random audits on care plans being updated weekly for four weeks and monthly for three months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations.