Failure to Develop and Update Comprehensive Care Plan for UTI After Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to develop and update a comprehensive care plan (CP) for a resident’s urinary tract infection (UTI) following readmission from the hospital. The resident was initially admitted with metabolic encephalopathy and later readmitted with a diagnosis of UTI. A Minimum Data Set (MDS) dated 10/25/2025 documented that the resident had moderate to severe cognitive impairment, was independent with several ADLs such as eating and bed mobility, but required maximal assistance for toileting and showering, partial assistance for dressing and transfers, and was frequently incontinent. The Medication Administration Record dated 1/8/2026 showed the resident was receiving Ciprofloxacin 500 mg by mouth in the morning for seven days for treatment of the UTI. Record review revealed no care plan problem, goals, or interventions addressing the UTI, including no documented monitoring parameters, comfort measures, or physician notification requirements related to this condition. The MDS nurse reported that the resident’s CP had not been updated since 10/16/2025 and acknowledged that it should be updated quarterly and upon each admission or readmission, but stated she intended to update the CP upon the resident’s next admission due to frequent hospitalizations. The DON confirmed that there was no CP addressing the UTI after the resident’s return from the hospital and stated that a comprehensive care plan should have been initiated for the UTI diagnosis with appropriate interventions and goals. Review of the facility’s policy on Comprehensive Care Plans – Timing, dated 1/2025, indicated that the interdisciplinary team is responsible for reviewing and revising the comprehensive care plan after each assessment and completing it within seven days and no more than 21 days after admission, which was not followed in this case.
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