Failure to Timely Revise Care Plans After Changes in Resident Condition and Treatment
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised in a timely manner for multiple residents, as required. For one resident who completed a course of antibiotics, the care plan continued to include interventions related to antibiotic administration and monitoring even after the medication was discontinued. Another resident's care plan still referenced fracture care for a left humerus fracture, despite the absence of a current diagnosis or physician orders related to a fracture. Additionally, a third resident's care plan included interventions for antipsychotic use, although the antipsychotic medication had been discontinued and was no longer part of the resident's treatment regimen. These deficiencies were identified through clinical record reviews, interviews, and examination of care plans and medication administration records. The MDS Coordinator confirmed responsibility for care plan revisions and acknowledged that care plans should have been updated to reflect changes in residents' conditions and treatments. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change, but this process was not followed for the residents in question.