Failure to Update Resident Care Plan Post-Antibiotic Therapy
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, as required by regulations. The deficiency was identified for one resident, who was cognitively intact and required assistance for daily care needs. The resident had been diagnosed with pneumonia and was on antibiotic therapy. The care plan, dated March 4, 2025, indicated that staff were to administer the antibiotic medication as ordered by the physician. However, the care plan was not updated when the resident's antibiotic therapy was completed. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the care plan should have been updated. The facility's policy, dated September 27, 2025, stated that care plans should be individualized and updated by the licensed nurse and interdisciplinary team as needed with changes as applicable.
Plan Of Correction
Resident 73's care plan has been updated to demonstrate discontinued orders and interventions appropriate to identified needs. A facility-wide sweep of all discontinued antibiotic therapy was conducted. Any issues identified were corrected at the time of discovery. The registered nurse assessment coordinator (RNACs) and licensed nursing staff were re-educated regarding timely resident care plan revisions when resident changes occur. The Assistant Nursing Home Administrator or designee will conduct audits to ensure that care plan revisions are completed timely, weekly for 4 weeks, then monthly for 2 months. Identified issues will be addressed at the time of discovery. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.