Failure to Update and Revise Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to reflect current care needs. Observations showed the resident, who was severely cognitively impaired and had multiple diagnoses including Parkinson's, dementia, chronic pain, and pressure injuries, was inconsistently using protective boots and compression stockings. The care plan in the electronic medical record (EMR) indicated the resident should wear compression stockings and foam boots in bed, but did not specify use of boots in the recliner, nor did it reflect that the resident was no longer able to walk or that compression stockings were discontinued per family request. Staff interviews revealed confusion and inconsistency regarding which care plan to follow, with some staff using a baseline care plan and others referencing the EMR, leading to discrepancies in care provided. Further review of the resident's records and staff interviews confirmed that the care plan was not updated to include new orders or changes in the resident's condition, such as the development of pressure wounds and changes in mobility status. The facility's own policies required that care plans be updated to reflect current wound status and treatment, and that changes in condition be reported and documented accordingly. However, the care plan did not accurately reflect the resident's current needs or physician's orders, resulting in a failure to provide consistent and appropriate care as required.