Failure to Develop Comprehensive Care Plan for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with specific and individualized interventions for a resident who required Enhanced Barrier Precautions. The facility's policy required that each resident have a care plan with measurable goals and timetables to address their medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. For the resident in question, the quarterly MDS assessment documented significant care needs, including an indwelling catheter, a wound infection, Multiple Sclerosis, and a Stage 4 pressure ulcer in the sacral region. Physician's orders specified the use of Enhanced Barrier Precautions, and signage was observed outside the resident's room indicating the required infection control measures for high-contact care activities. Despite these documented needs and orders, there was no evidence in the clinical record that a comprehensive care plan addressing the resident's Enhanced Barrier Precautions had been developed. This was confirmed by the Director of Nursing during an interview, who acknowledged the absence of such documentation. The deficiency was cited under 28 Pa. Code 211.12(d)(5) Nursing Services.