Failure to Update Care Plans Following Changes in Resident Care Needs
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for five residents. In several cases, care plans continued to list interventions or medications that had been discontinued, such as foley catheters and anticoagulant or antibiotic therapies. For example, one resident's care plan still indicated the presence of a foley catheter after it had been removed and was not re-inserted per physician orders. Another resident's care plan continued to reference anticoagulant therapy even after the medication had been discontinued, and similar discrepancies were found for residents who were no longer receiving antibiotics or anticoagulants, as confirmed by review of physician orders and medication administration records. These deficiencies were confirmed through interviews with the Director of Nursing, who acknowledged that the care plans had not been updated as required. The facility's policy required quarterly reassessment and interdisciplinary review of care plans, but documentation did not show that care plans were revised to reflect significant changes in residents' treatments or conditions. The lack of timely updates to care plans was identified through review of clinical records, policies, and staff interviews.