Failure to Develop Admission Care Plan for Resident with Pleurx Catheter
Penalty
Summary
The facility failed to develop a care plan upon admission for a resident who had a Pleurx catheter in place. The resident was admitted and re-admitted with diagnoses including malignant neoplasm of the prostate, pleural effusion, and neutropenia. Documentation showed that the resident required partial to full assistance with activities of daily living and mobility. Medical records indicated the Pleurx catheter was placed prior to admission due to recurrent pleural effusion. Despite this, no care plan specific to the management of the Pleurx catheter was created at the time of admission. Interviews with facility staff, including a Licensed Vocational Nurse, Registered Nurse Supervisor, and Director of Staff Development, confirmed that a care plan addressing the Pleurx catheter was not developed upon admission. Staff acknowledged the importance of timely care planning for medical devices to ensure proper monitoring, drainage, infection prevention, and clear staff guidance. Facility policies reviewed also required comprehensive, person-centered care plans to be developed upon admission, especially for residents with medical devices, but this was not followed in this case.