Failure to Care Plan for Immunocompromised Resident at High Risk for Infection
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident who was immunocompromised and at high risk for infection. The resident’s face sheet showed an original admission with a readmission date and diagnoses including diffuse large B-cell lymphoma, encounter for antineoplastic chemotherapy, and acquired absence of kidney. The resident’s MDS indicated intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Despite these documented conditions and functional needs, there was no care plan addressing the resident’s immunocompromised status. During an interview and concurrent record review with the DON, it was confirmed that licensed staff or the MDS Coordinator did not initiate a care plan upon admission to address the resident’s immunocompromised condition related to diffuse large B-cell lymphoma. The DON acknowledged that the care plan should have included interventions such as not cohorting the resident with others who had active infections and that the existing care plan was not comprehensive or person-centered. Review of the facility’s policy on comprehensive, person-centered care plans showed that care plans were required to include measurable objectives and timetables, be derived from a thorough assessment, describe needed services, and reflect recognized standards of practice, which was not done for this resident’s immunocompromised status.
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