Failure to Revise Care Plans After Cohorting with CDI-Positive Resident
Penalty
Summary
The deficiency involves the facility’s failure to revise comprehensive, person-centered care plans for two residents after they were cohorted with another resident who had a suspected and later confirmed Clostridium difficile (CDI) infection. Resident 1 was admitted with diagnoses including pulmonary embolism and sepsis, and later developed enterocolitis due to CDI, with symptom onset identified as occurring on 1/18/2026. A physician ordered stool collection for CDI testing on 1/18/2026, and a Change in Condition evaluation completed on 1/20/2026 documented CDI, diarrhea meeting CDI criteria, and placement of Resident 1 on contact isolation. Despite these developments and the infection-control implications, the care plans for the cohorted residents were not updated. Resident 2 had a history of diffuse large B-cell lymphoma, chemotherapy, and acquired absence of a kidney, with an MDS indicating intact cognition and a need for substantial/maximal assistance with toileting hygiene, showering/bathing, lower body dressing, and footwear. Resident 3 had diagnoses including hypertrophic cardiomyopathy, chronic kidney disease, type 2 DM, depression, and anxiety disorders, with an MDS showing moderately impaired cognition and a need for substantial/maximal assistance with toileting hygiene, lower body dressing, and footwear. Both residents were cohorted with Resident 1 when CDI was suspected and then confirmed, but their care plans were not revised to reflect this change in condition and exposure risk. During an interview and concurrent record review with the DON on 1/30/2026, it was confirmed that staff did not update the care plans for Residents 2 and 3 when they were cohorted with the CDI-positive resident. The DON stated that licensed staff and the MDS Coordinator were responsible for updating care plans and acknowledged that the existing care plans for these residents were not comprehensive or person-centered in light of the new circumstances. The facility’s own policy on comprehensive, person-centered care plans requires that care plans be derived from thorough assessment, describe services to meet residents’ highest practicable well-being, reflect current standards of practice, and be revised as residents’ conditions change. The failure to revise the care plans after the cohorting event constituted the cited deficiency.
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