Failure to Revise Care Plans to Reflect Current Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely and accurate manner for five residents, as required by regulations. For one resident, although a safety device evaluation, physician order, and consent for bed mobility bars were completed, the care plan was not updated to reflect the use of these devices, despite their presence in the resident's room and the resident's stated use of them for positioning. Another resident had an order for positioning rails, and these were in use, but the care plan did not include any information about them. In both cases, the Interim Director of Nursing (IDON) confirmed that the care plans should have been revised to include these devices. A third resident's care plan continued to reference repositioning bars, even though there was no assessment, order, or consent for their use, and the bars were not present in the resident's room. The resident confirmed that she no longer used the bars and was unsure when or why they were removed. The IDON acknowledged that the care plan was not updated to remove this intervention. Similarly, another resident's care plan included interventions for pain medication administration, but there were no orders for pain medication, no administration of such medication, and pain monitoring consistently indicated no pain. The IDON stated the care plan was initially created as a preventative measure but was not revised when it became clear the intervention was unnecessary. For the fifth resident, the care plan indicated the use of a psychotropic medication, but the medication had been discontinued and there were no current orders for it. The IDON confirmed that the care plan should have been updated to reflect the discontinuation. In all cases, the lack of timely care plan revisions meant that the documented plans of care did not accurately reflect the residents' current needs and interventions in place at the time of the survey.