Failure to Initiate and Implement Resident-Centered Care Plans for UTI and Constipation
Penalty
Summary
A deficiency occurred when nursing staff failed to initiate and implement resident-centered care plans for a resident who developed a urinary tract infection (UTI) and experienced constipation. The resident, who had a history of hemiplegia, hemiparesis, vascular dementia, anxiety, and muscle weakness, was admitted with significant cognitive impairment. After leaving the facility with her sister, the resident was hospitalized for stomach pain and diagnosed with an acute UTI, receiving treatment before returning to the facility. Despite being prescribed antibiotics for the UTI, nursing staff did not initiate a care plan specific to the UTI or antibiotic treatment, as confirmed by the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN). Both acknowledged that a care plan was not created, which was not in line with facility policy, and that typical interventions such as increased hydration and monitoring for systemic infection were not formally directed. Additionally, the resident experienced three days without a bowel movement, but no bowel care medications were administered as per the facility's bowel protocol. The care plan for constipation included interventions such as administering Milk of Magnesia and Dulcolax suppository if needed, but these were not implemented or documented. The DON was unable to confirm whether the resident received bowel care management or if it was simply not documented. The LVN stated that bowel care interventions are triggered in the electronic health record after three days without a bowel movement, but there was no evidence that these interventions were carried out. Facility policies required that care plans be reviewed and updated when there is a significant change in a resident's condition, and that nursing staff adjust treatment based on ongoing assessment. In these instances, the lack of initiation and implementation of care plans for both the UTI and constipation represented a failure to provide resident-centered care as outlined in facility protocols.