Failure to Revise and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were evaluated for effectiveness and revised as needed for three residents. In one case, after a resident experienced a fall resulting in a major injury and was sent to the ER, there were no new immediate interventions implemented, and the care plan was not updated to reflect changes or new strategies to prevent future falls. Staff interviews revealed that while fall interventions were generally communicated through care plans and staff meetings, the specific incident did not prompt a timely update or revision of the care plan, and documentation related to post-fall interventions was left incomplete. Another resident, who had a history of pathological hip fractures and anxiety, had discrepancies in her care plan. The care plan was not updated to reflect a new left hip fracture and continued to list an anti-anxiety medication that had been discontinued months earlier. Staff acknowledged that the care plan should have been revised to reflect these changes, but it was overlooked, resulting in outdated and inaccurate information regarding the resident's current condition and medication regimen. A third resident with a history of pressure ulcers and infection had care plans that were not updated to reflect the current status of their wounds or treatments. Although the infection had been treated effectively, the care plan still included outdated goals and interventions for previous stages of pressure ulcers and did not reflect the most recent changes in the resident's condition. Staff interviews confirmed that care plans should be updated with any significant change, but this was not consistently done.