Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans to reflect changes in residents' care needs for four residents. Resident 28, who was cognitively impaired and required dialysis, had a care plan indicating the use of a fistula for dialysis. However, observations revealed the use of a Central Venous Catheter instead, and the care plan was not updated to reflect this change. The Director of Nursing confirmed the oversight. Resident 33, who was cognitively intact and had a diagnosis of multi-drug resistant organisms, was initially on contact precautions due to ESBL - E. coli. Physician's orders later indicated that the resident was no longer on contact precautions, but the care plan was not updated to reflect this change. The Assistant Director of Nursing/Infection Preventionist confirmed that the care plan should have been updated. Resident 39, who was cognitively impaired and had no pressure injuries, was on Enhanced Barrier Precautions due to a chronic wound. Observations showed that the resident's pressure ulcers had resolved, but the care plan was not updated to reflect this. Similarly, Resident 68, who had a reopened Stage 3 pressure injury, did not have an updated care plan to include this condition. The Director of Nursing confirmed the care plan was not revised for Resident 68.
Plan Of Correction
1. Resident 28, 33, 39 and 68's care plans were updated. 2. Review of residents with central venous catheter, resolution of contact isolation, resolution of enhanced barrier precautions due to skin breakdown and new pressure ulcers were reviewed to ensure care plans were accurate. Registered Nurse Assessment Coordinator's were educated on ensuring timely updating of resident care plans is being completed. 3. Registered Nurse Assessment Coordinator or designee will audit three residents care plan with a central venous catheter, resolution of contact isolation, resolution of enhanced barrier precautions due to skin breakdown and new pressure ulcers weekly times four weeks and monthly times two months. 4. Results will be reviewed at the Quality Assurance Performance Improvement Meeting.