Failure to Revise Care Plan After Hospital Readmissions for Sepsis/Urosepsis
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was revised in a timely manner for one resident following two separate hospital readmissions for sepsis and urosepsis. The resident, who had multiple diagnoses including urosepsis, bullous pemphigoid, COPD, various malignancies, UTIs, schizophrenia, and anxiety, was readmitted to the facility after hospitalizations for sepsis/urosepsis related to urinary tract infections. Despite these significant changes in the resident's condition, the care plan was not updated to reflect the new diagnoses or to include appropriate monitoring and interventions for infection. Record review and staff interviews revealed that the care plan previously included interventions for monitoring signs and symptoms of UTI, but these interventions had been resolved prior to the resident's hospitalizations and were not reinstated upon readmission. The care plan also referenced a catheter, but all related interventions had been resolved months before the most recent hospitalizations. As a result, the care plan did not address the resident's current needs following the episodes of sepsis and urosepsis.