Failure to Develop and Implement Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who experienced a change in condition, specifically hematuria (blood in the urine). The resident, who had a history of prostate cancer, chronic kidney disease stage 3, and acute respiratory failure with hypoxia, was admitted and later readmitted to the facility. On the date of the change in condition, a physician's order for urinalysis was obtained due to hematuria, and a subsequent order for urine culture was placed for lower abdominal pain. However, there was no care plan created or revised to address the new onset of hematuria at that time. The resident's existing care plan addressed frequent incontinence and related issues but did not include interventions specific to the new condition of hematuria. Progress notes indicated that the urinalysis result was reported to the physician, but no new orders were given, and no change in condition (COC) note was created for the hematuria event. The lack of a COC note meant that the care planning process was not initiated for this new issue, and interventions to monitor and address hematuria were not implemented until several days later, after a positive urine culture result. Facility staff confirmed that the absence of a timely care plan for hematuria could result in a lack of monitoring and appropriate interventions.