Failure to Update Medical Orders and Care Plans After Treatment Changes
Penalty
Summary
The facility failed to update medical orders and care plans for two residents following significant changes in their treatment needs. For one resident, staff continued to monitor and document the status of a non-patent dialysis access site in the right upper arm, despite the resident reporting that the site was no longer in use and a new dialysis catheter had been placed in the right upper chest. Orders for monitoring the old access site, including auscultation and palpation, as well as infection checks, remained active and were carried out by staff until surveyor intervention. Documentation on the Treatment Administration Record reflected ongoing monitoring of the non-functional site, and the orders were not discontinued in a timely manner. For another resident, the facility did not update the physician's orders or the care plan after a C-collar was discontinued. The resident's records continued to include orders for skin integrity checks and monitoring of the C-collar placement, and the care plan still referenced the use of the C-collar for healing and protection. Nursing notes indicated that the resident was refusing the C-collar and that it was no longer needed, but these changes were not reflected in the official orders or care plan. The Director of Nursing confirmed that the necessary updates had not been made.