Failure to Update Care Plans to Reflect Resident Needs and Preferences
Penalty
Summary
The facility failed to revise and update care plans to accurately reflect the current needs and preferences of two residents. For one resident, although there was a physician order and a signed document indicating a Do Not Resuscitate (DNR) status, the care plan incorrectly stated that the resident was a full code and wished to be sent to the hospital for respiratory illness. The Director of Nursing confirmed that the care plan should have matched the resident's advanced directives and physician orders, but it did not. For another resident who experienced a decline in health, including increased time spent in bed and the development of two deep tissue pressure injuries, the care plan did not include new interventions to address the increased risk of skin breakdown, such as floating heels. The wound treatment nurse confirmed that the care plan should have been updated to reflect the resident's change in condition and to include additional pressure reduction interventions. Facility policy requires that care plans be revised as residents' conditions change, but this was not done in these cases.