Failure to Update Care Plan for New Pneumonia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's recent diagnosis of pneumonia. The resident, an elderly female with a history of pleural effusion, chronic obstructive pulmonary disease, and severely impaired cognition, was admitted with multiple respiratory conditions and was dependent on continuous oxygen therapy. Despite a physician's order for Doxycycline to treat pneumonia and documentation of the resident's ongoing respiratory symptoms, the care plan was not updated to include interventions specific to the new pneumonia diagnosis or the antibiotic treatment. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for updating care plans for new infections but had not done so for this resident following the resignation of the previous Infection Control Nurse. The DON acknowledged being aware of the pneumonia diagnosis and the antibiotic order but did not revise the care plan, believing existing respiratory care plans were sufficient. The administrator confirmed that the omission occurred during the transition between staff roles. The facility's policy requires comprehensive care plans with measurable objectives and timeframes for all identified needs, but this was not followed in this case.