Failure to Develop Comprehensive Care Plan for Resident with Permacath and EBP Needs
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for one resident who was admitted with multiple complex medical conditions, including Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, End Stage Renal Disease, and Muscle Weakness. The resident had a permacath inserted in the right chest for dialysis treatment, which was documented in the nursing admission assessment. Facility policy required the development and implementation of a comprehensive care plan for each resident, including measurable objectives to address all identified medical and nursing needs. Despite these requirements, review of the resident's comprehensive care plan revealed that it did not address the presence of the permacath or the need for Enhanced Barrier Precautions (EBP), both of which were indicated by facility policy for residents with indwelling medical devices. The resident was observed with a clean and dry permacath site, and received dialysis three times per week. The DON confirmed that the care plan should have included the vascular access and EBP, and acknowledged that the facility failed to do so for this resident.