Failure to Update Care Plan for Resident with New PICC Line After Hospital Readmission
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident following a significant change in condition after hospital readmission. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was readmitted with a vascular access device (PICC line) for IV antibiotic therapy due to bacteremia and a urinary tract infection. Despite physician orders and documentation indicating the presence of the PICC line and the need for ongoing IV antibiotics, the care plan was not updated to reflect the new vascular access device within the required timeframe. Observations conducted several days after readmission confirmed the continued presence of the PICC line in the resident's right upper extremity. Interviews with facility staff, including the Interim DON, confirmed that the care plan should have been updated within seven days of readmission, but this was not done. The care plan only addressed the resident's ADL deficits and infection risk, with no mention of the PICC line or related care needs.