Failure to Update Baseline Care Plan for Resident with New COVID-19 Diagnosis
Penalty
Summary
The facility failed to ensure that a baseline care plan was implemented to address a resident's immediate needs following admission. Upon admission, the resident was diagnosed with sinusitis and was to receive medication for three days, which was reflected in the initial care plan. However, the following day, the resident tested positive for COVID-19 and was placed in respiratory isolation with droplet precautions, as observed by signage on the resident's door and confirmed by staff interviews. Despite these developments, there was no documented evidence in the clinical record that the baseline care plan was updated to include the resident's new diagnosis of COVID-19 and the need for droplet precautions. The Assistant Director of Nursing confirmed that the care plan was not revised to reflect these changes.