Failure to Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and needs of three residents. For one resident with protein-calorie malnutrition and bipolar disorder, observations showed the use of a specialty mattress and fall mats, but these interventions were not documented in the care plan addressing fall risk. Another resident, admitted with syncope, collapse, muscle weakness, and unsteadiness, experienced multiple syncopal and unresponsive episodes, yet her care plan did not mention her diagnosis of syncope or the actual episodes she experienced. Additionally, a third resident with depression and anxiety disorder had a physician order for Seroquel to address psychosis and visual hallucinations, but the care plan did not include a focus area related to antipsychotic medication use. These deficiencies were identified through clinical record reviews, observations, and staff interviews, indicating that the care plans were not consistently updated to reflect significant changes in residents' conditions or treatments.