Failure to Monitor Effectiveness of Rash Treatment per Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident by not monitoring the effectiveness of treatment for the resident's rash. The resident, who had diagnoses including metabolic encephalopathy and type 2 diabetes mellitus, was cognitively intact and required supervision or assistance with activities of daily living such as upper body dressing and personal hygiene. The care plan specifically directed staff to monitor the effectiveness of the rash treatment and to notify the physician as needed. A review of nursing progress notes after the care plan was established showed no documentation that nurses monitored the effectiveness of the rash treatment. During interviews and record reviews, the Director of Nursing confirmed that there was no supporting documentation to indicate that the required monitoring had occurred, as outlined in the resident's care plan. Facility policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed in this instance.