Care Plans Not Updated to Reflect Residents' Current Needs
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to accurately reflect the current care needs and interventions for three residents. For one resident with a history of hypertension and previously documented as receiving a diuretic for edema and hypertension, the care plan continued to indicate diuretic use despite no evidence in the clinical record or Medication Administration Record (MAR) that the medication was being administered. Another resident, identified as an elopement risk with a history of dementia, anxiety, depression, and bipolar disorder, had a care plan that listed an outdated code alert bracelet number and expiration date, which did not match the current physician order or the bracelet observed on the resident. A third resident, who was cognitively impaired and required assistance with care needs, had a care plan intervention for antibiotic therapy related to a urinary tract infection, but there was no documentation in the clinical record or MAR of a current infection or antibiotic administration. In each case, interviews with the Nursing Home Administrator confirmed that the care plans should have been revised to reflect the residents' current conditions and interventions, but this was not done in a timely manner as required by facility policy and regulatory standards.