Failure to Update Care Plan for Infection Management and Precautions
Penalty
Summary
The facility failed to revise a resident's care plan to include interventions for infection management after the resident tested positive for MRSA and was placed on transmission-based precautions. The resident, who was cognitively intact but dependent on staff for activities of daily living, had diagnoses including diabetes, renal insufficiency, and COPD. Following a positive sputum culture for MRSA and a diagnosis of pneumonia, the resident was prescribed multiple antibiotics and placed on precautions upon return from the hospital. Staff were instructed to wear full PPE when caring for the resident, and later, modified precautions were implemented based on a physician's order due to the resident's mental health needs. Despite these changes in the resident's condition and care requirements, the care plan was not updated to reflect the necessary infection control interventions or the modified precautions. Interviews with nursing staff confirmed that the care plan should have included these interventions, as staff rely on the care plan to guide resident care. The director of nursing also stated that care plans are updated by nurses and reviewed by staff for changes. However, the care plan for this resident did not include the required transmission-based precautions or infection management interventions, and a care planning policy was requested but not provided.