Failure to Develop Care Plan for Resident with ESBL-Positive UTI
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for a resident who tested positive for extended spectrum beta-lactamase (ESBL) producing Escherichia coli (E. coli). The resident, who had a history of chronic obstructive pulmonary disease, urinary tract infection, and atrial fibrillation, was readmitted to the facility and required substantial assistance with activities of daily living due to moderately impaired cognition. Despite laboratory results confirming a urinary tract infection with ESBL-producing E. coli and the initiation of antibiotic therapy and contact precautions, there was no evidence that an interdisciplinary team (IDT) care plan meeting was conducted to address this change in condition. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the facility's policy required the development of a care plan in response to such changes in a resident's condition. Review of the resident's records and care plans from the relevant period showed that this requirement was not met, resulting in a failure to document and implement a care plan tailored to the resident's new diagnosis and needs.