Failure to Timely Revise Care Plans After Change in Condition
Penalty
Summary
The facility failed to timely revise and update care plans for a resident following significant changes in condition, specifically after a fall resulting in a left femur fracture and subsequent surgery. The resident, who had diagnoses including dementia, schizophrenia, and diabetes, experienced two falls and was hospitalized for surgical repair of a displaced intertrochanteric fracture. Upon readmission, new pain management orders were implemented, but the pain care plan was not revised to reflect the increased pain level or the new medication regimen. The last update to the pain care plan occurred prior to the falls and surgery. Additionally, the resident's skin care plan was not updated to address post-surgical site care or infection prevention measures following the hospital readmission. The last revision to the skin care plan predated the surgical event, and no new interventions were documented for the surgical site. During an interview, the DON acknowledged that the care plans had not been revised to address the resident's current needs. The facility was unable to provide a policy for care plan updates and revisions when requested.