Failure to Develop Individualized Care Plan for Antibiotic Use
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident who was cognitively intact but required substantial assistance with daily care tasks. Clinical records showed that the resident had physician's orders for daily amoxicillin and Methenamine Hippurate for the prevention of urinary tract infections (UTIs), due to a history of UTIs with sepsis. Despite these ongoing medication orders, there was no documented evidence that a care plan was created to address the resident's specific care and treatment needs related to the use of these antibiotic medications. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that a care plan should have been developed for the resident's antibiotic use.