Failure to Develop Baseline Care Plan for Infection and Antibiotic Use
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was admitted with multiple infections, including a multi-drug resistant organism (MDRO), urinary tract infection, wound infection, enterococcus infection, and a fracture of the left lower leg. Upon admission, the resident was receiving intravenous (IV) antibiotic therapy, including cefepime, daptomycin, and doxycycline, and was placed on contact precautions for Carbapenem-resistant Enterobacteriaceae (CRE). Facility policy requires that a baseline care plan addressing immediate health and safety needs be developed within 48 hours of admission. A review of the resident's clinical record, physician orders, and progress notes confirmed the presence of active infections and ongoing antibiotic therapy, as well as the implementation of contact precautions. However, the care plan initiated at admission did not address the resident's infection status, use of antibiotics, or the need for contact precautions. This omission was confirmed by the Director of Nursing during an interview, who acknowledged that no care plan had been developed for these critical aspects of the resident's care.