Care Plan Omission for Pneumonia Diagnosis
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 diagnosis of pneumonia for one resident. The resident, an elderly female with a history of dementia and secondary hypertension, was readmitted to the facility and subsequently diagnosed with pneumonia, as documented in the Infection Surveillance Monthly Report. Despite the confirmed diagnosis and the initiation of antibiotic therapy (Levaquin), the resident's care plan did not reflect the pneumonia diagnosis or related care interventions. Interviews with the DON and Administrator revealed uncertainty as to why the pneumonia diagnosis was not included in the care plan. The DON indicated that she would typically be notified of changes in a resident's condition through central intake, floor nurses, or audits, which would prompt an update to the care plan. However, in this instance, the care plan was not updated to address the pneumonia, resulting in a missed need for the resident. The facility's policy requires that care plans incorporate all identified problems and risk factors, and be revised as residents' conditions change, which was not followed in this case.