Failure to Document Change of Condition and Develop Care Plans for Acute Events
Penalty
Summary
The facility failed to ensure comprehensive care planning and appropriate documentation of change of condition (COC) for two residents. For one resident, who had diagnoses including acute respiratory failure, muscle weakness, and type 2 diabetes, there was an incident where the resident passed out while sitting on a shower chair and was assisted to the floor. Despite the event, there was no care plan or COC documentation completed regarding the incident. The charge nurse present at the time did not document the incident, assuming the Registered Nurse Supervisor (RNS) would handle the assessment, physician notification, and care plan initiation, but this was not done. The Director of Nursing (DON) confirmed that the RNS should have assessed and documented the COC and implemented a care plan to monitor the resident's status after the incident. For another resident with diagnoses including type 2 diabetes, dementia, and depression, there was a documented infection of the left big toe, for which bacitracin ointment was ordered and administered. However, there was no COC documentation or comprehensive care plan developed for the infection. The Infection Preventionist (IP) and DON both acknowledged that a care plan should have been initiated to guide staff in providing appropriate care and monitoring the resident's condition. The absence of a care plan meant that staff lacked guidance on interventions and monitoring for potential decline related to the infection. Review of facility policies confirmed that changes in condition require prompt assessment, documentation, physician notification, and care plan development. The policies also require that all services, changes in condition, and progress toward care plan goals be documented in the resident's medical record to facilitate communication among the interdisciplinary team. In both cases, the facility did not follow its own policies regarding COC documentation and care planning for acute changes in residents' conditions.