Failure to Develop and Implement Individualized Care Plan for Central Line and Surgical Wound
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, individualized care plan for a resident who had a newly placed central venous catheter port and a surgical incision wound. The resident, who had been admitted from an acute care hospital with multiple diagnoses including liver cell carcinoma, a femur fracture, cerebral ischemia, and major depressive disorder, was observed with a dressing on his right upper chest. The resident reported that nurses had not changed his dressing and that staff did not use gowns or gloves when providing care. There was also no enhanced barrier precautions (EBP) signage on the resident's door, despite the presence of a central line and surgical wound. Record review revealed that the resident's care plan did not include any interventions or monitoring instructions for the central venous catheter port or the surgical incision. The Infection Preventionist confirmed that there was no care plan for the catheter line, even though it had been placed the previous week. The Infection Preventionist stated that a care plan should have been created upon the resident's return to the facility after the procedure, and that such a plan is necessary to guide staff in monitoring for infection, identifying symptoms, and knowing when to contact a physician. Interviews with staff indicated a lack of awareness and use of care plans in daily care. Certified Nursing Assistants reported relying on verbal reports rather than reviewing care plans, and the Director of Nursing acknowledged that the absence of a care plan for the catheter line meant the resident did not have a specific, individualized plan to meet his needs. Facility job descriptions and policies reviewed also emphasized the importance of care plans in ensuring appropriate care and communication among staff, but these were not followed in this instance.