Failure to Develop Comprehensive Care Plan for Resident with Feeding Tube
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's medical, nursing, mental, and psychosocial needs. Specifically, a resident who was admitted with a feeding tube did not have enhanced barrier precautions (EBP) included in her care plan, despite requiring them. Record review showed that the care plan acknowledged the feeding tube but omitted EBP, and there was no physician order for EBP in the resident's consolidated orders. The resident was cognitively intact, dependent on staff for all activities of daily living, incontinent of bowel and bladder, and required a feeding tube. Interviews with facility staff, including the MDS nurse, DON, and regional reimbursement nurse, confirmed that the care plan was incomplete and did not reflect all necessary interventions for the resident. Staff acknowledged that the comprehensive care plan should have included EBP and that its omission could result in a lapse of care. The facility's policy requires that care plans be person-centered and address all identified needs, but this was not followed in this instance.