Failure to Develop Comprehensive Care Plans for Residents on Contact Precautions
Penalty
Summary
The facility failed to develop comprehensive care plans addressing transmission-based precautions for three residents who required Contact Precautions due to ESBL (Extended Spectrum Beta Lactamase Resistance) infections. Specifically, the care plans for these residents did not include a focus or problem area for Contact Isolation, nor did they identify ESBL as the organism necessitating these precautions. Observations confirmed that Contact Precaution signage was posted on the doors of the affected residents' rooms, and physician orders indicated the need for such precautions. However, the care plans either omitted this information entirely or incorrectly listed the type of precautions in place. The residents involved had significant medical histories, including urinary tract infections, urinary incontinence, and other genitourinary conditions associated with ESBL. Despite the presence of physician orders and visible signage indicating the need for Contact Precautions, the care plans did not reflect these requirements. Facility leadership, including the Administrator and Assistant Director of Nursing/Infection Preventionist, acknowledged that the care plans should have included the appropriate problem areas and interventions for transmission-based precautions. At the time of the survey, the facility did not have an MDS/Care Plan Coordinator.