Failure to Update Care Plans for Skin and Nutrition
Penalty
Summary
The facility failed to timely revise and update care plans for two residents, resulting in care plans not reflecting the current status and needs of the residents. Resident #33, who has a history of dementia, major depressive disorder, chronic systolic heart failure, anxiety, and hypertension, was found to have a suspected deep tissue injury (SDTI) on her right heel and ankle. Despite this, the care plan for skin impairment had not been revised since February and did not mention the current skin conditions. The Unit Manager acknowledged that the care plan should have been updated to include a short-term care plan for the SDTI and the actual skin issue, but it was only revised after being notified of the oversight. Resident #63, with diagnoses including dementia, major depressive disorder, encephalopathy, and hypertension, experienced a significant weight loss of 17% over six months. Despite being started on supplement shakes to aid in weight gain, the care plan for nutrition had not been updated since 2021 and did not include a specific plan for addressing the weight loss. The Certified Dietary Manager admitted to not creating a specific care plan for weight loss, instead incorporating it into the general nutritional care plan. This lack of timely updates and specific care plans for the residents' changing conditions led to deficiencies in their care management.