Failure to Update and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in response to residents' changing needs and conditions for four residents. For one resident with a history of femur fracture, end-stage renal disease, and diabetes, the allergy care plan was not updated to reflect current medication allergies, resulting in the administration of a medication listed as an allergy. Another resident with chronic respiratory failure, COPD, and congestive heart failure did not have a care plan meeting held to review and revise the care plan after admission, despite being cognitively intact and expressing interest in attending such a meeting. Additionally, a resident with dementia, diabetes, and hypertension developed a pressure ulcer, but the care plan was not updated to reflect the new skin condition or subsequent changes in the wound's status. The skin integrity care plan only referenced a rash and did not address the progression of the pressure sore, despite multiple wound care assessments documenting changes. Staff interviews revealed a lack of awareness and insufficient staffing support for care plan updates, contributing to the deficiencies.