Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update and revise the care plans for two residents to reflect their current care needs. For one resident, the care plan was not updated to indicate the discontinuation of Coumadin and the initiation of Apixaban for anticoagulation therapy. Additionally, the care plan did not document the resident's use of a foley catheter leg bag, which was preferred for dignity. These omissions were confirmed by the Director of Nursing during interviews. For another resident, the care plan inaccurately documented surgical wounds on the palms, which were actually scars from previous surgeries. This error was identified during a skin and wound assessment shortly after the resident's admission, but the care plan was not revised to reflect the correct information. The Director of Nursing confirmed that the care plan should have been updated to remove the incorrect information about surgical wounds.
Plan Of Correction
1. Care plan for resident 7 and resident 11 were reviewed and updated by the Director of Nursing. Neither resident suffered any adverse effects. 2. The Director of Nursing or designee will review the care plans for all current residents with catheters, have wounds or on anticoagulation medication for accuracy in anticoagulation medication, for residents with catheters who preference leg bags along with correct wound documentation. Any identified care plans will be updated upon discovery. 3. The Director of Nursing or designee will educate all staff who are responsible for completing and updating the care plan so that to reflect a resident's new orders, treatments, and interventions. 4. The Director of Nursing or designee will audit any changes to resident preferences to ensure comprehensive care plans are updated to reflect changes 2 times a week for 2 weeks then monthly for 2 months to assure the resident's anticoagulant therapy/catheter bag preferences wound changes are reflected. The Director of Nursing or designee will report on the results of the audit to the facility's Quality Assurance Committee. 5. Date of compliance 3/5/2025.