Failure to Revise and Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise and update comprehensive care plans to address the individual care needs of two residents. For one resident with diagnoses including schizophrenia, cerebral infarction, hemiplegia, and impaired cognition, the care plan interventions related to falls and cognitive function were not revised or modified after multiple falls and changes in cognitive status. The assistant Director of Nursing confirmed that the care plan had not been updated to reflect these changes, despite facility policy requiring care plans to be re-evaluated and modified as necessary to reflect changes in care, service, and treatment. For another resident with a history of intracerebral hemorrhage, kidney contusion, and sepsis, the care plan for an antibiotic remained active even after the antibiotic course was completed. The Director of Nursing confirmed that the care plan should have been resolved but was not. These failures were identified through interviews, medical record reviews, and review of facility policies and procedures, and placed the residents at risk of not receiving appropriate, consistent, and individualized care.