Failure to Initiate Baseline Care Plan for Antibiotic Therapy
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was prescribed an antibiotic for a respiratory problem. Upon review, it was found that the resident, who had diagnoses including dementia, a history of falls, and hypertension, was admitted and started on an antibiotic regimen for a cough. However, no care plan was created to address the use of the antibiotic, including monitoring for side effects or the effectiveness of the therapy, during the period the medication was administered. Interviews with nursing staff and the Director of Nursing confirmed that it was the responsibility of licensed nurses to initiate a care plan immediately upon starting new medications, and that this was not done in this case. Facility policy and job descriptions reviewed also indicated that baseline care plans should be completed within 48 hours to address immediate health and safety concerns. The absence of a care plan for the antibiotic was acknowledged by staff and leadership during the survey.