Failure to Revise Care Plan After PICC Line and Enhanced Barrier Precautions Initiated
Penalty
Summary
The facility failed to revise the care plan for one resident following a significant change in their medical status. According to the facility's policy, the interdisciplinary team is responsible for developing and updating a comprehensive, person-centered care plan that incorporates all identified problem areas and risk factors. In this case, a resident with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Chronic Kidney Disease, and Urinary Tract Infection was admitted and later had a Peripherally Inserted Central Catheter (PICC) placed in her right upper arm. Despite an order for Enhanced Barrier Precautions (EBP) following the PICC insertion, the care plan was not updated to reflect this new intervention. Medical record review showed that the resident was cognitively intact at the time of the deficiency, as indicated by a BIMS score of 15. Observation confirmed the presence of the PICC line, and documentation verified the order for EBP. During an interview, the DON acknowledged that it was the facility's expectation to revise care plans when EBP was ordered, and confirmed that this was not done for the resident after the PICC line was inserted.