Failure to Update Care Plan After Resolution of Yeast Infection
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, specifically neglecting to update the care plan to reflect the resolution of a yeast infection. The resident, an elderly female with diagnoses including essential primary hypertension, unspecified dementia, and depression, had a severe cognitive impairment as indicated by a BIMS score of 1. Her care plan continued to list an active yeast infection even after the prescribed course of Terconazole vaginal suppositories was completed, and treatment had ended. Interviews with facility staff, including the ADON, DON, and ADM, confirmed that the care plan was not updated to indicate the yeast infection had resolved. The ADON acknowledged responsibility for updating the care plan and admitted to missing this update. The DON and ADM both stated it was expected for the care plan to be updated to reflect the resident's current condition. Facility policy requires the interdisciplinary team to develop and maintain comprehensive care plans with measurable objectives and timeframes, but this was not followed in this instance.