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 the development of a bruise on the right cheek. The resident, who had a diagnosis of vascular dementia, was admitted in April 2025. Documentation showed that on 4/17/25, the resident sustained facial bruising, and a physician's order was issued on 4/18/25 to monitor the discoloration every shift. Despite these events, the resident's care plan was not updated to reflect the new condition or the required monitoring interventions. Interviews with facility staff confirmed that the expectation was to update the care plan whenever a resident experienced a change in condition. A review of the care plan on 4/23/25 revealed that it did not include information about the bruising or the monitoring order. The facility's policy also required care plans to be revised as residents' conditions changed, but this was not followed in this instance.
Plan Of Correction
Plan to Monitor Performance: 1. Medical Records will audit all SBARs and COC reports to ensure that care plans are updated per this POC. Any missing or unrevised care plans will be presented to the DON and nurse responsible to be corrected. A record of the audits will be reported to the DON. 2. The Director of Nursing will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly for 3 months. The QAPI committee will evaluate the effectiveness of interventions and make changes as needed until substantial compliance is achieved and maintained. The facility will complete all corrective action with F657 by 5/26/25.