Failure to Review and Revise Care Plans After Changes in Resident Status
Penalty
Summary
The facility failed to review and revise the care plans for two residents as required by both facility policy and federal regulations. For one resident with a history of long-term anticoagulant use and peripheral vascular disease, the care plan included a focus on potential bleeding and bruising due to aspirin and Plavix use. However, after the resident was hospitalized and both medications were discontinued upon return to the facility, the care plan was not updated to reflect this significant change in medication regimen, despite a comprehensive assessment and care plan review being completed. For another resident with cerebral palsy and spondylosis, a fall with major injury occurred, and a subsequent fall risk evaluation identified the resident as high risk for falls. Despite this, the care plan did not include a current focus on fall risk, and the previous fall care plan had been marked as resolved. Staff interviews confirmed that the care plan should have addressed the resident's ongoing fall risk. These findings demonstrate that the facility did not ensure care plans were consistently reviewed and revised in response to changes in residents' conditions and assessments.