Failure to Update and Implement Person-Centered Care Plans After Change in Condition
Penalty
Summary
The facility failed to review, revise, and implement person-centered comprehensive care plans for two residents following significant changes in their conditions. For one resident who underwent a left hip hemiarthroplasty, the care plan did not specify the frequency of dressing changes, instructions for bathing with respect to the surgical site, or clarify the resident's weight-bearing status. Interviews with staff revealed a lack of awareness regarding the resident's surgical history and uncertainty about wound care and mobility instructions, despite existing physician orders. The care plan lacked clear guidance, and staff were unable to reference it for necessary care details. Another resident experienced a fall resulting in a laceration above the left eyebrow, which required repair with sutures. The care plan for this resident did not include instructions for wound care of the laceration, even though physician orders specified the wound care regimen and suture removal timeline. Staff interviews and record reviews confirmed that the care plan was not updated to reflect these new care needs after the resident returned from the hospital. Both the Director of Nursing and the Administrator acknowledged that the interdisciplinary team did not update the care plans after the residents returned from the hospital, as required by facility policy. The policy mandates that care plans be reviewed and revised after significant changes in a resident's condition or after hospital readmission. The lack of updated, accessible care plans meant that staff could not easily determine or implement the required care for these residents.