Failure to Care Plan JP Drain for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had a Jackson Pratt (JP) drain following surgery. Despite physician orders specifying that the JP drain should be emptied and drainage documented each shift, the site cleansed and dressed every shift, and the site monitored for signs of infection, these interventions were not included in the resident's care plan. The resident's admission MDS assessment did not mention the JP drain, and the care plan, as of its last revision prior to surveyor intervention, did not address the presence or care of the JP drain. Observations confirmed the resident had a JP drain in place, and interviews with staff revealed that the omission was not recognized until brought to their attention by surveyors. The MDS coordinator and other members of the interdisciplinary team (IDT) were responsible for developing and updating care plans, but the JP drain was not care planned despite being present since admission. The Director of Nursing (DON) and Administrator both acknowledged that the care plan should reflect all aspects of a resident's care, and that the omission could impact the resident's care. Facility policy required that care plans be comprehensive, person-centered, and kept current, but this was not followed in the case of the resident with the JP drain.