Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to develop and update comprehensive, person-centered care plans with measurable objectives and timeframes for three residents, as required by policy and regulation. For one resident with end stage renal disease and metabolic encephalopathy, the care plan was not revised after a hospitalization for pneumonia, despite a significant change in condition and new interventions such as nebulizer treatments and oxygen therapy. Documentation showed that the care plan's target dates and interventions were not updated to reflect the resident's most recent hospitalization and treatment needs. Another resident with chronic obstructive pulmonary disease and a tracheostomy received intravenous antibiotics for a positive sputum culture, but the care plan did not identify or address this new treatment. Interviews with staff confirmed that the care plan should have been updated when the antibiotic order was received, and that failure to do so could affect the ability of nurses to provide appropriate care. A third resident with diabetes, hypertension, and moderate cognitive impairment was found to possess cigarettes in his room, but his care plan did not address tobacco use. Staff interviews revealed that although the resident was not identified as a smoker on admission, he did smoke while at the facility, and this should have been included in his care plan. The facility's policy required care plans to be updated upon significant changes in condition, new treatments, or upon readmission from the hospital, but these requirements were not met for the residents involved.