Failure to Update Care Plan Following Change in Isolation Precautions
Penalty
Summary
A resident with diagnoses including non-traumatic brain dysfunction, stroke, and high blood pressure was admitted to the facility and assessed as having severely impaired cognition, impaired range of motion, and total dependence on staff for all activities of daily living. The resident was initially placed on Contact Isolation Precautions for C. difficile shortly after admission, and later, a physician's order directed that Enhanced Barrier Precautions (EBP) be implemented every shift due to tube feeding. Despite these changes, the resident's care plan, last revised on the date of the initial isolation, was not updated to reflect the new EBP order. Observations during the survey confirmed that EBP signage was present on the resident's door, and interviews with the Infection Preventionist and DON revealed that the care plan should have been updated immediately to reflect the change from Contact Isolation to EBP. The care plan continued to reference the discontinued C. difficile precautions and did not include the current EBP requirements, indicating a failure to revise the care plan in accordance with the resident's updated care needs and physician's orders.