Failure to Revise and Update Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to review and revise care plans for three residents following significant changes in their conditions or care needs. For one resident with a history of depression, schizophrenia, and bipolar disorder, the care plan addressing fall risk was not updated after the resident experienced an unwitnessed fall resulting in minor injuries. The Director of Nursing confirmed that the care plan should have been revised with additional interventions to guide staff in preventing further falls and injuries. Another resident, diagnosed with dementia, stroke, aphasia, and hemiplegia, did not have quarterly Interdisciplinary Team (IDT) meetings as required, nor was an IDT meeting held after the resident was sent to a general acute hospital due to bleeding gums. The Social Services Designee acknowledged that the absence of regular and post-hospitalization IDT meetings led to a year-long delay in care plan revision, re-evaluation, and implementation, excluding input from the IDT and the resident’s responsible party or public guardian. A third resident, with diagnoses including bradycardia, syncope, hypertension, and major depressive disorder, had a care plan that was not updated to reflect the use of a new continuous cardiac monitor device after returning from a cardiovascular appointment. The care plan continued to focus on routine heart rate assessments without addressing the specific interventions required for the new device. Both the Licensed Vocational Nurse and the Director of Nursing confirmed that the care plan should have been revised to include the updated interventions related to the cardiac monitor.