Failure to Update Care Plans for Self-Administration and Wound Dressing
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents to reflect their current health status and needs. One resident, who had been admitted with Sjögren's syndrome and required supervision with activities of daily living, was observed to have Carboxymethylcellulose Sodium Ophthalmic Solution (eye drops) at her bedside and reported self-administering the medication daily since admission. However, there was no documented assessment, physician order, or care plan indicating that she was permitted or able to self-administer her medication, as required by facility policy and federal regulations. Another resident, admitted with a history of stroke and requiring supervision with self-care, was observed with both hands wrapped in self-adhering elastic bandages. The treatment nurse confirmed that the resident chose to keep his hand amputations covered, but there was no care plan with goals or interventions addressing the use of the bandages. A certified nursing assistant also noted that the resident needed assistance with care, including eating meals, due to the bandages. In both cases, the Director of Nursing acknowledged that the care plans should have been updated to reflect the residents' current needs and interventions. The facility's policies require that care plans be comprehensive, person-centered, and revised as residents' conditions change, but these requirements were not met for the two residents identified.
Plan Of Correction
Plan of Correction completion date: 6.30.25 F 657