Failure to Update Care Plans Following Changes in Resident Condition and Treatment
Penalty
Summary
The facility failed to review and revise care plans for two residents following significant changes in their conditions and treatment. For one resident with chronic obstructive pulmonary disease, new onset bilateral lower extremity edema was observed, and a provider ordered both a diuretic (Torsemide) and leg elevation while sleeping. Despite these changes, the resident's care plan was not updated to reflect the new diagnosis, medication, or provider recommendations. The care plan printout showed no revisions after the onset of edema or the initiation of new interventions. Another resident with a history of falls, depression, and anxiety experienced behavioral changes, including agitation and confusion, which led to referrals to behavioral health services and the initiation of two different anti-anxiety medications within a two-month period. The resident's care plan did not address the use of anti-anxiety medications, the recent treatment for pneumonia, or the referral to behavioral health services. Interviews with facility staff confirmed that care plans were not updated to reflect these changes in the residents' care needs.