Failure to Update Care Plan Following Exacerbation of Neurological Symptoms
Penalty
Summary
The facility failed to update the care plan for a resident experiencing an exacerbation of neurological symptoms. The resident, who had a history of cerebral palsy, metabolic encephalopathy, and reduced mobility, began exhibiting new and severe spastic movements of the upper and lower extremities. These symptoms represented a significant change from the resident's baseline condition, as confirmed by the Director of Nursing, who noted that the resident had not previously displayed such jerking movements. Despite the onset of these new symptoms and the implementation of 1:1 supervision, the resident's care plan was not promptly revised to address the change in condition or to include new interventions specific to the exacerbation. Record review showed that the resident's care plan, initially created to address musculoskeletal alterations related to cerebral palsy, had not been updated with new interventions until the day of the survey. The facility's policy requires that care plans be revised as information about the resident and their condition changes, and that all identified problem areas be incorporated into the care plan. However, the care plan for this resident did not reflect the recent changes in neurological status or the need for additional interventions until after the deficiency was identified by surveyors.