Failure to Revise Care Plans with Updated Resident Information and Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information and interventions for four residents. For one resident, documentation showed repeated refusals of showers, but the care plan was not updated to address these refusals or to specify actions staff could take to encourage bathing. Another resident experienced a fall and was subsequently placed under increased monitoring and redirection, but these interventions were not added to the care plan. In both cases, staff confirmed that the care plans were not revised as required following changes in the residents' conditions or care needs. Additionally, a resident with a history of falls and dementia had new interventions ordered, including a fall mat, bed in the lowest position, and a new medication for anxiety, but these were not incorporated into the care plan. Another resident was prescribed an additional anti-anxiety medication, but the care plan was not updated to reflect this change. Interviews with the MDS Coordinator and DON confirmed that the care plans did not include these new interventions or medications, despite expectations that care plans be revised with any changes in resident care.