Failure to Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans for four residents, resulting in deficiencies related to the provision of care and services. For one resident with multiple stage 4 pressure ulcers and immobility, the care plan included the use of a low air loss mattress (LALM) set to the resident's weight. However, the LALM was observed to be set at an incorrect setting of 350, which did not correspond to the resident's actual weight of 162 lbs. Nursing staff were unaware of the correct weight and did not follow the care plan instructions, potentially compromising wound management. Another resident receiving diclofenac gel for pain management had an order specifying application to the hands, but nursing staff were observed applying the medication to the knees. The medication administration record (MAR) showed inconsistent documentation of application sites, with some entries indicating use on both lower extremities and others lacking documentation. The care plan did not specify which joints required pain management, and the order was not clarified until after the deficiency was identified. A third resident with a gastrostomy tube (G-tube) for enteral feeding had a care plan that did not provide adequate guidance for nursing staff on G-tube care, despite the resident's complex medical history including hemiplegia, diabetes, and dysphagia. Additionally, a resident with a seizure disorder and behavioral health diagnoses had care plans for falls, behaviors, and seizure precautions that were not revised to reflect current needs, despite ongoing changes in the resident's condition. These failures to revise and update care plans were confirmed through interviews and record reviews, and were not in accordance with the facility's own policy requiring ongoing assessment and care plan revision.