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West Carroll Care Center Did Not Always Follow Care Plans for Residents Who Were Later Hospitalized With Potentially Avoidable Urinary Tract Infections

The West Carroll Care Center (the Nursing Home) (operating in Oak Grove, Louisiana) did not always provide service to its residents in accordance with their care plans, as required by Federal regulations, before the residents were hospitalized with urinary tract infections. Specifically, the Nursing Home did not monitor and document residents' hydration status, monitor and document the residents' conditions, and document residents' urine appearances as their care plans required.

These deficiencies occurred because the Nursing Home did not have policies and procedures to ensure that its staff provided services in accordance with its residents' care plans. As a result, the residents were at increased risk for contracting infections and becoming hospitalized.

We recommended that the Nursing Home implement its newly developed policies and procedures requiring that (1) its nursing staff follow residents' care plans and (2) the director of nursing or a designee conduct reviews to ensure that the nursing staff follows residents' care plans. The Nursing Home agreed with our findings and stated that it has implemented corrective actions, including new and revised policies, staff education, and continued audits to ensure staff compliance with policies and procedures.

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Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201