Failure to Revise Care Plans for Skin Irritation and Nebulizer Use
Penalty
Summary
Staff failed to update and revise care plans for two residents following changes in their care needs. For one resident, despite documented complaints of chronic itchiness and physician orders for topical medication, the care plan did not reflect the use of the prescribed lotion or address the ongoing skin irritation. Nursing progress notes and interviews with both the resident and staff confirmed the presence of chronic skin irritation and the use of topical medication, yet this was not incorporated into the resident's care plan. For another resident, the care plan was not updated to include the use of Albuterol via nebulizer or the storage method for the nebulizer, despite multiple administrations of the medication as documented in the Medication Administration Record. Observations and staff interviews confirmed that the resident continued to use the nebulizer and that it was not stored according to facility expectations. The resident's preference for storage and the ongoing need for nebulizer treatments were not documented in the care plan, as confirmed by nursing staff and the Assistant Director of Nursing.