Failure to Revise and Update Care Plans for Changes in Resident Condition
Penalty
Summary
The facility failed to ensure that care plans were developed and revised to reflect the current status of three residents. For one resident with dementia and severe cognitive impairment, a rash on the right ankle was documented in a Skin & Wound Evaluation but was not added to the resident's care plan. The Director of Nursing (DON) confirmed that the care plan was not updated to include this new condition. Another resident, admitted with a history of stroke, left-sided weakness, and a pressure ulcer, had documented skin damage to the tail bone in a Skin and Wound Evaluation, but the care plan did not reflect any skin breakdown. The DON also confirmed this omission during an interview. A third resident, who was bedbound with dementia and severe cognitive deficits, had a physician's order for comfort care, but no corresponding care plan was developed to address this order. The resident's daughter was identified as the responsible party for healthcare decisions. The DON confirmed that a care plan for comfort care was not created. These findings were based on interviews, record reviews, and a review of the facility's policy and procedure, which requires care plans to be reviewed and revised with any change in condition.