Failure to Timely Develop and Implement Care Plan for Infection and Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident who returned to the facility with a presumptive positive test for legionnaires disease and an order for azithromycin to treat pneumonia. Upon review, it was found that the care plan addressing legionnaires disease was not created until several days after the resident's return, and the care plan for azithromycin was not developed until after the medication course had already been completed. The delay in care plan development was confirmed by both the registered nurse and the director of nursing, who acknowledged that the care plans should have been established at the time of the resident's return and initiation of treatment. The resident in question had a history of hereditary and idiopathic neuropathy, a history of falls, and was assessed as having severely impaired cognitive skills, requiring moderate assistance with daily activities. The resident was admitted with multifactorial pneumonia, including legionnaires disease, and was prescribed azithromycin for a three-day course. Despite these significant medical needs and the initiation of antibiotic therapy, the facility did not promptly create or update the resident's care plan to reflect these new diagnoses and treatments. Interviews with facility staff, including the infection preventionist, confirmed that the lack of timely care plan development could potentially delay necessary care and services. Review of facility policy indicated that comprehensive, individualized care plans with measurable objectives and timetables are required for each resident, and that these plans should be updated as the resident's condition changes. The failure to develop and implement appropriate care plans in a timely manner was a direct violation of these policies.