Failure to Include Transmission-Based Precautions in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan that included transmission-based precautions for one resident. Facility policy dated 12/2023 required development of a comprehensive person-centered care plan for each resident with all information necessary to properly care for them. The resident was admitted with diagnoses including a Stage 4 sacral pressure ulcer, chronic Hepatitis C, and a herpes viral infection of the urogenital system. An admission MDS showed the resident was cognitively intact and documented the presence of a pressure ulcer and viral hepatitis. Physician orders dated 9/26/2025 placed the resident on transmission-based precautions for a wound organism, and an order dated 9/27/2025 directed staff to paint lesions on the inner vulva with betadine daily. Review of the comprehensive care plan dated 7/15/2025 showed the resident was care planned for pressure ulcers with enhanced barrier precautions, but there was no care plan addressing the ordered transmission-based precautions. Observations on 9/28/2025 confirmed that transmission-based precautions were in place at the resident’s room, with appropriate signage and PPE available at the door. In an interview, the Infection Preventionist confirmed the resident was on transmission-based precautions due to copious wound drainage and a diagnosis of viral Hepatitis C. In a separate interview, the DON confirmed that the resident’s care plan had not been developed to include transmission-based precautions, despite the existing orders and implemented precautions.
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