Failure to Update Care Plan After Resident Sustained Bruising
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced a change in condition, specifically a bruise to the right cheek. The resident, who was admitted with vascular dementia, sustained facial bruising as documented in the SBAR Communication Form and Progress Note. Following this incident, a physician's order was issued to monitor the discoloration on the resident's right cheek every shift. Despite these documented changes and the facility's policy requiring care plans to be updated as residents' conditions change, the care plan for this resident was not revised to reflect the new injury. Both a licensed nurse and the Director of Nursing confirmed during interviews that the expectation was to update the care plan after such changes, but this was not done in this case.