Failure to Update Care Plan for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to revise the care plan for a resident who was receiving a prophylactic antibiotic for recurrent urinary tract infections (UTIs). The resident, who was moderately cognitively impaired and had diagnoses including stroke, diabetes, renal insufficiency, and an indwelling urinary catheter, had a physician's order for daily Cephalexin starting from 02/13/25. Review of the resident's medication administration records confirmed that the antibiotic was administered daily over several months. Despite the ongoing use of the prophylactic antibiotic, the resident's comprehensive care plan did not include any information regarding this medication regimen. The Director of Nursing confirmed that the care plan should have been updated to reflect the prophylactic antibiotic use, as ordered by the resident's urologist. Facility policy requires that the comprehensive care plan describe all services provided to maintain the resident's highest practicable well-being, but this was not done in this case.