Failure to Timely Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to timely update and revise care plans for two residents, resulting in deficiencies related to individualized care. For one resident with a history of epilepsy and a physician's order for padded side rails to reduce injury risk, the care plan was not updated to include this intervention until over two months after the order was issued. The care plan for seizure disorder was only revised to include padded side rails well after the physician's directive, despite staff acknowledging that timely updates are necessary to ensure consistent implementation of safety measures. Another resident with an indwelling catheter for urinary retention had a care plan that was not reviewed or revised for more than six months, despite facility policy requiring quarterly reviews. The care plan, which included interventions to monitor for urinary tract infection and proper catheter bag positioning, was last updated in November of the previous year and not subsequently reviewed, even though the resident continued to require catheter care. Interviews with facility staff confirmed that care plans are expected to be reviewed quarterly and after any change in condition, to ensure interventions remain effective and all pertinent information is included. The failure to adhere to these review and revision schedules was acknowledged by staff, who stated that such lapses could result in inadequate care and supervision. Facility policy also mandates comprehensive, person-centered care plans that are regularly updated to reflect residents' needs as identified in assessments.