Failure to Develop Person-Centered Care Plan for Antibiotic Therapy
Penalty
Summary
Surveyors identified a failure to develop and implement a person-centered care plan addressing the use of specific antibiotics for one resident. The resident was admitted with diagnoses including an unspecified thoracic vertebra wedge compression fracture, essential hypertension, and generalized muscle weakness. A History and Physical dated 12/5/2025 documented that the resident had capacity to understand and make decisions, while the MDS from the same date indicated severely impaired cognitive skills for daily decisions and dependence on staff for toileting, showering, and dressing. On 12/11/2025, the physician ordered cephalexin 500 mg twice daily for seven days for a UTI, following a complaint of urinary discomfort on 12/10/2025 and subsequent urinalysis results. The Medication Administration Record showed the resident received cephalexin from 12/11/2025 at 5 p.m. through 12/14/2025 at 5 p.m. A care plan dated 12/11/2025 and revised on 12/26/2025 addressed a history of UTI with general interventions to administer medications as ordered and monitor for side effects, but it did not identify or individualize care for the specific antibiotic therapy. On 12/14/2025, the physician ordered ciprofloxacin 500 mg twice daily for seven days for UTI, and the MAR showed the resident received ciprofloxacin from 12/15/2025 at 9 a.m. through 12/21/2025 at 5 p.m. During interviews and record reviews, the Infection Preventionist stated that residents on antibiotics such as cephalexin and ciprofloxacin are to be monitored every shift for signs and symptoms of infection and adverse reactions, with documentation in progress notes, and that a care plan for antibiotic use should be developed on the day antibiotics start and revised with any change in antibiotic medication. The IP confirmed there was no care plan developed for the resident’s use of cephalexin and ciprofloxacin and noted that without an updated or revised care plan, nurses might miss interventions and potentially delay care. The DON stated that nurses should update the care plan based on monitoring of the antibiotic and that the resident’s care plan should be person-centered and revised as the resident’s condition changes, consistent with the facility’s Comprehensive Person-Centered Care Plans policy, which requires measurable objectives, timeframes, and revisions as conditions change. RN 1 acknowledged that the facility updates care plans with general interventions and stated there was no direct effect on the resident if the antibiotic care plan was not revised.
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