Failure to Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to update and revise care plans for two residents as required. For one resident with moderate cognitive impairment and multiple diagnoses, including a neurogenic bladder and use of an indwelling urinary catheter, the care plan inaccurately documented the use of a leg urinary drainage bag. Observations and staff interviews confirmed that the resident had not used a leg bag for approximately six months due to leakage issues, and instead carried a standard urinary drainage bag. Despite this change, the care plan continued to reference the leg bag and related interventions, which did not reflect the resident's current care needs or preferences. For another resident with intact cognition, the care plan listed the code status as Cardiopulmonary Resuscitation (CPR), with interventions to call an ambulance and transfer to the hospital. However, the physician order summary and the current Iowa Physician Order for Scope of Treatment (IPOST) both indicated a Do Not Resuscitate (DNR) status, which was also confirmed by staff. The care plan was not updated to reflect this change in code status, resulting in a discrepancy between the resident's documented wishes and the care plan interventions.