Failure to Include MDRO and Protective Precautions in Baseline Care Plan
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one resident. The resident was admitted with multiple significant diagnoses, including pancytopenia, small B-cell lymphoma, nontraumatic intracerebral hemorrhage, cognitive communication deficit, anemia, and a documented multidrug-resistant organism (MDRO) infection. Hospital discharge orders listed MDRO, and the resident’s electronic health record contained an infection prevention and control alert for a wound with E. coli MDRO, with an onset date matching the hospital discharge. Despite this information, the baseline care plan created the day after admission did not include any interventions related to MDRO. The baseline care plan also omitted interventions for the use of Modified Protective Environment Precautions, even though the resident was placed on these precautions as an alternative to neutropenic precautions. A subsequent observation showed a sign posted next to the resident’s door indicating Modified Protective Environment Precautions were in place. In interviews, the infection prevention coordinator confirmed the MDRO diagnosis and the use of Modified Protective Environment Precautions, and the interim DON confirmed that the resident’s care plan lacked interventions for MDRO and the need for Modified Protective Environment Precautions, despite these being necessary based on the resident’s condition and orders.
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