Failure to Monitor and Update Care Plan for Resident on Antibiotic Therapy
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the highest practicable well-being for one of twelve sampled residents. Specifically, the facility did not monitor a resident who was receiving antibiotic treatment for a urinary tract infection (UTI) and did not update the resident's care plan to address the treatment interventions and management of the UTI. The facility's policies require that a baseline care plan be developed to meet immediate health and safety needs and that significant changes in a resident's condition prompt an interdisciplinary review and care plan revision. However, after the resident experienced a change in condition and was started on antibiotics, there was no documented evidence that the resident's condition or response to antibiotic therapy was monitored as required. Additionally, the resident's care plan was not updated to reflect the new treatment for the UTI. Interviews with nursing staff confirmed that the care plan lacked information about the UTI management and that there was no documentation of monitoring during and after the antibiotic course. The facility's own policies and CDC guidance highlight the importance of monitoring for adverse effects during antibiotic therapy, but these were not followed in this case.