Failure to Update Care Plan for Resident's Toe Infection
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's toe infection. The resident, who had a history of hypertension and diabetes mellitus and was admitted with severely impaired cognition, was identified as having left second toe cellulitis, for which an antibiotic was ordered. Despite the identification of the infection and the initiation of treatment, the care plan was not updated or revised to reflect the new condition. Interviews with facility staff, including the Infection Prevention Nurse, an LVN, and the Director of Nursing, confirmed that the care plan should have been implemented or revised at the time the infection was identified. The facility's policy also indicated that care plan goals and objectives should be reviewed and revised when there is a significant change in a resident's condition. However, no care plan addressing the toe infection was created or updated, resulting in a lack of documented interventions and monitoring for the resident's new infection.