Failure to Develop Comprehensive Care Plan for Antibiotic Use
Penalty
Summary
The facility failed to ensure that a person-centered comprehensive care plan was developed for a resident regarding antibiotic medication use. This deficiency was identified during a recertification survey. The resident in question had a diagnosis that required antibiotic medication, as documented in their Admission Minimum Data Set 3.0 assessment, which also noted mild cognitive impairment and the use of anticoagulant medication. Despite the physician's orders for antibiotics, there was no documented evidence of a comprehensive care plan addressing the antibiotic use. A registered nurse, responsible for reviewing care plans, admitted to not having reviewed the resident's chart since admission and acknowledged the absence of a care plan to monitor for side effects related to the antibiotics.
Plan Of Correction
Plan of Correction: Approved March 7, 2025 Immediate action(s) taken for the resident(s) found to have been affected include: - Director of Nursing or designee updated the person centered comprehensive care plan of resident #30 to address antibiotic medication use. Identification of other residents having the potential to be affected was accomplished by: - Residents admitted whom require the development of person-centered comprehensive care plans with objectives and timeframe's to meet the resident's needs have the potential to be affected. Action taken/systemic change put into place to reduce the risk of future occurrence include: - Director of Nursing or designee will in-service registered nurses on the Comprehensive Care Planning Policy by 3/31/25. - Clinical Care Manager or designee will ensure person-centered comprehensive care plans are developed with objectives and timeframe's to meet the resident's needs by 4/1/25. How the corrective action will be monitored to ensure the deficient practice will not reoccur: - Director of Nursing or designee will audit 10% of resident Comprehensive Care Plans. Beginning on 4/1/25 audits will be monthly x6 months with a goal of 100% compliance. Findings will be reported during QAPI. Date of Completion and Person Responsible: 4/20/25, Director of Nursing