Failure to Include IV Antibiotic Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the inclusion of IV antibiotic therapy administered via a central line. The resident, an adult female with diagnoses including partial intestinal obstruction, type 2 diabetes, and atrial fibrillation, was admitted following abdominal surgery and was receiving meropenem IV antibiotics through a central catheter. Although her care plan noted a skin impairment related to the central catheter, it did not address the ongoing IV antibiotic therapy, despite physician orders and documented administration of the medication. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans. The Regional MDS Coordinator, DON, and ADON each provided differing accounts of who was responsible for ensuring the care plan reflected the resident's IV antibiotic therapy. The ADON acknowledged that the omission could result in staff being unaware of the need to monitor for side effects, and the Administrator confirmed that the care plan should have included the IV medication as part of the resident's care. Review of facility policy indicated that comprehensive care plans should describe all services to be furnished to meet the resident's needs.