Failure to Revise Care Plans for Assist Bar Use and Hospice Admission
Penalty
Summary
Staff failed to revise and update care plans for two residents following significant changes in their care needs. For one resident with multiple diagnoses including Parkinson's disease, abnormalities of gait, and polyosteoarthritis, an evaluation documented the use of bilateral assist bars for bed mobility and transfers, with the resident's consent. Despite the presence of assist bars on the bed and the resident's use of them for repositioning and mobility, the care plan did not include any reference to assist bar use. The Director of Nursing confirmed that the care plan was not updated to reflect this intervention. For another resident with a history of atherosclerotic heart disease, dementia, and hypertensive heart disease with heart failure, a medical order was issued to admit the resident to hospice care. However, the care plan, last updated several months after the hospice order, did not address hospice care or services. The Director of Nursing acknowledged that the resident was on hospice and that the care plan should have included this information, but it had not been updated accordingly.