Failure to Include Recurrent UTI Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a significant history of urinary tract infections (UTIs). The resident, who had severe cognitive impairment and required assistance with all activities of daily living, had multiple diagnoses including hypertension, renal insufficiency, non-Alzheimer's dementia, and morbid obesity. The resident's medical record documented several episodes of UTIs over a period of months, with corresponding antibiotic and preventive treatments ordered by the physician. Despite this documented history and ongoing risk, the resident's care plan did not include any mention of UTIs, the history of recurrent infections, goals of treatment, or interventions to monitor, prevent, or address UTIs. Interviews with facility staff, including a registered nurse clinical coordinator and the director of nursing, confirmed that the care plan should have included the resident's history of UTIs and related interventions. Both staff members acknowledged the importance of documenting such information to ensure staff awareness and timely response to symptoms. The facility's own policy required comprehensive, person-centered care plans that incorporate measurable objectives, timetables, identified problem areas, and risk factors, none of which were present in the resident's care plan regarding UTIs.