Failure to Revise Care Plans for Changes in Condition and New Interventions
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were revised to reflect their current care needs and interventions. For one resident with renal insufficiency undergoing dialysis, a change in condition was documented when the resident's right arm became swollen and the dialysis site exhibited green discharge. Although the care plan included monitoring and reporting signs of infection, it was not updated to specifically address this new change in condition. Both the ADON and DON confirmed that the care plan was not revised following the incident. For another resident with a respiratory problem, the care plan addressed difficulty breathing but did not include the administration of oxygen as an intervention, despite a physician's order for oxygen use as needed for shortness of breath. The resident was observed with a portable oxygen tank, and staff verified the existence of the physician's order, but acknowledged that the care plan had not been updated to include this intervention. The DON confirmed these findings during a review.