Failure to Update and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect the current needs and preferences of four residents. For one resident with diabetes and muscle weakness, observations showed a CPAP mask left out on the bedside stand according to the resident's preference, but the care plan did not document this preference. Another resident with diabetes and protein-calorie malnutrition was observed wearing bilateral pressure offloading boots, yet the care plan addressing pressure ulcer risk did not include the use of these boots. A third resident with dementia, depression, and atrial fibrillation was prescribed Apixaban, an anticoagulant, but the care plan did not reflect the use of this medication. Additionally, a resident with a history of cerebral infarction and hypertension was observed using a left arm sling, but the care plan did not mention the use of the sling. In each case, staff interviews confirmed that these interventions or preferences should have been included in the respective care plans.