Failure to Implement and Revise Resident-Centered Care Plan for UTI and Hernia
Penalty
Summary
The facility failed to implement and revise a resident-centered care plan for a resident with multiple diagnoses, including urinary tract infection (UTI) and hernia. The resident's admission record documented several significant medical conditions, such as UTI, delirium, benign prostatic hyperplasia, muscle weakness, chronic kidney disease, hypertension, glaucoma, Alzheimer's, anxiety, and malignant neoplasm of the spleen. The Minimum Data Set (MDS) indicated severe cognitive impairment. Despite these diagnoses, the care plan report did not include documentation or interventions related to the care of the UTI or hernia. During interviews, the MDS coordinator/nurse acknowledged that all diagnoses should be care planned to ensure staff awareness and appropriate monitoring, especially for infections like UTI and conditions such as hernia. The coordinator admitted to not reviewing all relevant diagnosis information and stated it was their responsibility to ensure these conditions were included in the care plan. Facility policy and job descriptions require the development and implementation of individualized care plans for each resident, but this was not done for the resident in question, resulting in a deficiency.