Failure to Include MDRO Precautions, Bed Rails, and CPAP Use in Resident Care Plans
Penalty
Summary
Surveyors identified that the facility failed to develop and implement accurate, comprehensive care plans for multiple residents as required. One resident with diagnoses including pancytopenia, small B-cell lymphoma, nontraumatic intracerebral hemorrhage, cognitive communication deficit, and anemia was admitted with a hospital discharge diagnosis of a multidrug-resistant organism (MDRO) and an infection prevention alert for wound and E. coli MDRO. Despite this, the resident’s care plan dated the day after admission did not include any interventions related to MDRO or the facility’s Modified Protective Environment Precautions, even though a sign for these precautions was posted by the resident’s door. The Infection Prevention Coordinator confirmed the MDRO diagnosis and the use of Modified Protective Environment Precautions, and the Interim DON confirmed that these interventions were not reflected in the care plan and should have been. Another resident, admitted with lymphedema, chronic pain, bipolar disorder, adjustment disorder, and hypothyroidism, had a physician order for assist/side rails x2 starting shortly after admission. Observation showed quarter-size bed rails on both upper sides of the bed, and the resident reported using the side rails for mobility and repositioning. However, review of the resident’s care plan revealed no intervention addressing the use of side rails. The Interim DON confirmed that the care plan should have included the use of side rails but did not. A third resident, admitted with COPD with acute exacerbation, vascular dementia, oropharyngeal dysphagia, Crohn’s disease, and insomnia, was observed with a CPAP machine next to the bed and stated that the CPAP was used every night since admission. Review of this resident’s care plan showed no interventions related to CPAP use. The Interim DON confirmed that the facility failed to develop and implement a care plan that included the resident’s use of a CPAP machine and stated that residents are expected to have care plans that include all required interventions, including CPAP use.
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