Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised after a change in a resident's condition. Specifically, a resident who had been residing in the facility since March 2022 was referred by a nurse to therapy for a right-hand contracture, with the referral dated 9/12/24. A subsequent therapy evaluation on 10/11/24 confirmed the presence of the contracture. Despite this change in condition, a review of the resident's records showed that the care plan was not updated to reflect the new contracture. Interdisciplinary team (IDT) care plan meetings were held on 1/16/25 and 4/10/25, but there was no documentation indicating that the care plan had been revised to address the right-hand contracture. The Director of Nursing (DON) confirmed in an interview that it was her or the unit manager's responsibility to update care plans with every change in a resident's condition, but the records did not show that this was done for the resident's contracture.