Failure to Update Care Plan for Resident with UTI, Sepsis, and COVID-19
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. The care plan did not address the resident's current urinary tract infection (UTI), history of UTIs, or recent diagnoses of severe sepsis, E. coli bacteremia, and COVID-19 following a hospital discharge. Despite the resident having physician orders for antibiotics and cranberry capsules for UTI management, these interventions and the underlying conditions were not reflected in the care plan. Additionally, the resident's Minimum Data Set (MDS) did not include her history of UTI, sepsis, COVID-19, or antibiotic use. Observations and interviews revealed that the resident was non-communicative and unable to provide information about her condition. The Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's current UTI status and that the lack of updates could prevent nursing staff and CNAs from providing appropriate care. The DON also stated that the MDS coordinator, who is responsible for care plans, was unavailable, and that she would begin assisting with care plan updates. The administrator was unaware that the resident's UTIs were not included in the care plan and confirmed that both the MDS coordinator and DON were responsible for care plan management. The facility's policy requires that care plans be used to guide daily care routines and be updated to reflect changes in residents' conditions. Staff are expected to report changes to the nurse supervisor and MDS coordinator, and documentation must be consistent with the care plan. In this case, the failure to update the care plan with the resident's current and past medical conditions, as well as prescribed treatments, resulted in a deficiency identified by surveyors.