Failure to Update Comprehensive Care Plans for Residents with Changing Clinical Needs
Penalty
Summary
The facility failed to update and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies in addressing their clinical needs. For one resident with a history of periprosthetic fracture, left knee pain, and depression, the care plan did not identify pain as a problem or include goals and interventions for pain management, despite multiple physician orders for various pain medications and documented administration of these medications for moderate to severe pain. Additionally, the care plan did not address the resident's use of unauthorized controlled substances found in their room, nor did it include interventions for monitoring or education related to this issue. Another resident, admitted with diagnoses including dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies, had a care plan that failed to address seizure management and chronic myeloproliferative disorder, both of which were documented in hospital discharge records. The care plan did not include goals or interventions for seizure control or for the management and monitoring of the blood disorder, despite new orders for medication and the need for ongoing monitoring of blood cell and platelet counts. Interviews and policy reviews confirmed that the care plans were not updated following significant changes in the residents' conditions or upon receipt of new diagnoses and treatment orders. Facility policy required care plans to be revised to reflect changes in condition and to ensure continuity of care, but this was not done for the residents in question.