Failure to Develop and Implement Individualized Care Plan for Hepatic Encephalopathy
Penalty
Summary
The facility failed to develop and implement an individualized care plan for one resident who was reviewed. According to the facility's policy, a comprehensive, person-centered care plan with measurable objectives and timetables should be created and updated for each resident, especially when there are significant changes in condition or new clinical needs. For the resident in question, clinical records showed a diagnosis of hepatic encephalopathy and a physician's order for long-term antibiotic therapy with Rifaximin. Despite these documented needs, there was no evidence that a care plan was created to address the resident's hepatic encephalopathy or the ongoing requirement for antibiotic treatment. This deficiency was confirmed through review of the resident's clinical records, facility policies, and staff interviews. The DON acknowledged that no care plan was in place for the resident's hepatic encephalopathy or long-term antibiotic use. The lack of a care plan was found during a review of the resident's quarterly MDS assessment and physician's orders, which indicated the need for such interventions.