Failure to Include VP Shunt Management in Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan addressed the presence of a ventriculoperitoneal (VP) shunt and included interventions for monitoring shunt malfunction for a resident with a history of traumatic brain injury, dementia, and a VP shunt. The resident's care plan did not mention the VP shunt or provide guidance on recognizing or responding to signs and symptoms of shunt malfunction, despite the resident having a documented diagnosis of mechanical complication of ventricular intracranial shunt and physician orders related to wound care at the shunt site. The care plan only addressed risks related to skin integrity and wandering, omitting any reference to the shunt or its management. Interviews with nursing staff and facility leadership revealed a lack of awareness and documentation regarding the resident's VP shunt. Staff were not initially informed of the shunt upon the resident's admission, and the care coordinator was unsure if the care plan included the shunt. The director of nursing acknowledged that a care plan for the VP shunt should have been in place, and the administrator confirmed that the absence of such a care plan would hinder appropriate nursing response to shunt-related complications. The facility's care planning policy required interventions to be based on comprehensive assessment, which was not followed in this case.