Failure to Revise Care Plans for Infection Control and Dialysis Access
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs of two residents. For one resident who had previously tested positive for COVID-19, the care plan continued to indicate the need for enhanced barrier precautions (EBP) even after the resident was no longer contagious. Observation revealed that there was no EBP signage on the resident's door, and the MDS Coordinator confirmed that the EBP focus should have been resolved once the resident was no longer infectious. The facility's policy requires care plans to be reviewed and revised by the interdisciplinary team after each assessment, but this was not done in this case. For another resident receiving dialysis, the care plan listed interventions related to a shunt in the left subclavian area, including monitoring for bruit and thrill, and avoiding blood pressure readings and blood draws from the shunted arm. However, the resident was actually using a central venous catheter (CVC) in the left groin for dialysis, and the care plan and physician orders were not updated to reflect this change. Additionally, there was no documentation of required checks for bruit and thrill at the shunt site in the treatment administration record. The DON acknowledged that the orders needed to be updated to match the resident's current dialysis access.