Failure to Update Care Plans for Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in resident care needs for four residents. Resident 8, who has dementia, mistakenly used Calmoseptine on her dentures instead of denture cream. Despite a new intervention to remove creams from the bedside, the care plan was not updated, and Calmoseptine was still found in the resident's bathroom. Resident 26, who was on an anticoagulant, had her medication discontinued, but her care plan was not updated to reflect this change. Resident 53, who has a catheter due to neuromuscular dysfunction of the bladder, had a treatment for a skin tear that was discontinued, yet the care plan still indicated ongoing treatment. Resident 66, who is at risk for falls, experienced a fall from a high bed, and the immediate intervention was to remove the bed remote from reach. However, the care plan was not updated to include this intervention. Interviews with the Director of Nursing confirmed that the care plans for these residents were not updated as required.
Plan Of Correction
The facility corrected the care plans for residents R8, R26, R53, and R66 immediately when notified of the errors. No other care plan errors affecting other residents have been identified. All licensed staff will be re-educated on the care plan policy. The Director of Nursing or designee will review five care plans weekly for four weeks and then five care plans monthly for three months.