Failure to Revise Care Plans After Assessment Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for two out of three residents reviewed for care planning. For one resident, the care plan for Activities of Daily Living and Bed Mobility was not updated following a physical therapy assessment and recommendations. The physical therapy assessment determined that the resident required maximum assistance of two staff members for bed mobility, but the care plan continued to reflect only partial/moderate assistance by one staff member. This lack of communication and care plan update resulted in the resident receiving care from only one staff member, during which the resident rolled out of bed and suffered a fractured hip. Another resident's comprehensive care plan for antipsychotic medication management was not revised to include goals and interventions when a gradual dose reduction was performed. The resident's Zyprexa dosage was decreased, but the care plan did not reflect this change or include monitoring parameters for the dose reduction. Interviews with nursing staff confirmed that the care plan should have been updated to document the medication change and to monitor for any complications related to the dose reduction, but no such documentation was found. The facility's own policy required that care plans be updated with measurable objectives and timeframes to address residents' needs as identified in assessments, and that changes in condition or treatment be promptly reflected in the care plan. Despite this, the interdisciplinary team did not update the care plans in response to significant changes in residents' conditions or treatments, as evidenced by the lack of documentation and the adverse event that occurred.