Failure to Revise Care Plan for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of urinary tract infections (UTIs) to include the ongoing use of prophylactic antibiotics. The resident's electronic medical record documented multiple diagnoses, including chronic kidney disease, anxiety disorder, dehydration, hypertension, restlessness, agitation, dementia, and anemia. The resident's Minimum Data Set indicated moderately impaired cognition, occasional incontinence, and the use of several medications, including an antibiotic. The care plan addressed incontinence risk and skin care but did not mention the resident's history of UTIs or the use of prophylactic antibiotics. Physician orders consistently directed staff to administer Nitrofurantoin daily for UTI prevention over several months, with no documented stop date or physician rationale for the ongoing use. The administrative nurse confirmed the care plan should have included the prophylactic antibiotic use for the resident's UTI history. Additionally, the facility was unable to provide a policy regarding care plan timing and revisions when requested.