Failure to Revise Care Plans Following Changes in Resident Status and Medication Orders
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to reflect changes in residents' status and care needs for two residents. For one resident with diagnoses including dementia and type 2 diabetes mellitus, the care plan was not updated to include a dementia care plan, despite the diagnosis being present since admission. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan should have been revised to address the resident's dementia. For another resident with diagnoses of dementia, anxiety disorder, and depression, the care plan did not document the use of an antipsychotic medication, even though there was a current physician order for olanzapine. Additionally, the care plan still included an antianxiety medication that had been discontinued, and did not reflect the change in medication orders. The Director of Nursing confirmed that the care plan should have been updated when the medication orders changed. These findings were based on facility policy review, clinical record review, and staff interviews.