Failure to Revise Care Plans After Significant Resident Incidents
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents following significant changes in their conditions. For one resident with dementia, osteoporosis, and a history of repeated falls, the care plan was not updated after a fall occurred. Despite documentation of a fall on 4/19/2025 and subsequent assessment by the Interdisciplinary Team (IDT), no new interventions or revisions were made to the resident's fall risk care plan. The care plan continued to reflect previous interventions without addressing the recent incident, and the resident experienced another unwitnessed fall on 5/22/2025. For another resident with dementia and dysphagia who was dependent for most activities of daily living, the care plan was not revised after the resident repeatedly pulled out her nasogastric (NG) tube. Nursing staff confirmed that the care plan was not updated after incidents on 8/12/2024 and 4/24/2025, despite the increased risk of aspiration and the need for additional interventions. Both the Licensed Vocational Nurse (LVN) and Registered Nurse Supervisor (RNS) acknowledged that the care plan should have been revised after each occurrence to address the ongoing issue. Interviews with nursing staff and the Director of Nursing (DON) confirmed that care plans are intended to be updated when interventions are not effective or when a resident's condition changes. The facility's policy also indicated that care plans should be revised as new information becomes available. However, in both cases, the care plans remained unchanged after significant events, resulting in repeated incidents for both residents.