Failure to Update Care Plan After Change of Condition
Penalty
Summary
The facility failed to update and revise a resident's care plan following a change of condition for one of three sampled residents reviewed under the Accidents care area. The resident, who had diagnoses including Parkinsonism, ataxic gait, and unspecified dementia, experienced right shoulder pain that was not anticipated. The resident's Minimum Data Set indicated severely impaired cognitive skills and required varying levels of staff assistance for daily activities. On the date of the change of condition, a stat X-ray was ordered for the resident's right shoulder. Despite the change of condition and the new physician order, the resident's care plan for pain, which had been initiated earlier, was not reviewed or revised to reflect the new development. The Director of Nursing confirmed that the care plan was not updated after the change of condition, even though facility policy requires care plans to be reviewed and updated after significant changes in a resident's condition. The failure to update the care plan was identified during a review of records and interviews with facility staff.