Failure to Develop Comprehensive Care Plan for UTI History
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of urinary tract infections (UTIs). The resident, who was admitted to the facility with a diagnosis of a UTI and has a history of UTIs, was prescribed Macrobid and Nitrofurantoin MCR as preventive measures. Despite these medical interventions, the resident's care plan did not include a focus on managing or preventing UTIs. During an interview, the Nursing Home Administrator confirmed that a comprehensive care plan addressing the resident's history of UTIs should have been developed. This oversight was identified through a review of the resident's clinical records, which highlighted the absence of a care plan tailored to the resident's specific medical needs related to UTIs.
Plan Of Correction
1. Resident 43 care plan was updated during survey to reflect history of urinary tract infections. Licensed staff will be educated on ensuring development of the resident care plan to include Urinary Tract Infection prevention for Residents with History of urinary tract infections. 2. Resident care plans for residents with history of Urinary Tract infections days will be audited to ensure the care plan includes measures to monitor and prevent future urinary tract infections. 3. DON or designee Audits for accurate care plan documentation for new Residents with history of urinary tract infections will continue weekly for 4 weeks, monthly for 2 months. 4. All audits and findings will be submitted in the Quarterly QAPI committee meetings.