Failure to Update and Revise Care Plan After Resident Re-Admission
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for one resident following their re-admission. The resident, who had diagnoses including non-ST elevation myocardial infarction, type 2 diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, and dependence on renal dialysis, was discharged and then re-entered the facility. Upon review, the resident's active care plan included interventions for medications such as aspirin and diuretics, which were not currently ordered for the resident. Instead, the resident had an active order for Plavix (Clopidogrel Bisulfate) for blood clot prevention, but this was not accurately reflected in the care plan. There was no order for aspirin or diuretic medications, yet these remained as focuses and interventions in the care plan. Interviews with the LPN and RN responsible for care plans revealed that they did not attend care plan meetings and only reviewed care plans during quarterly MDS assessments. Both staff members acknowledged that the care plan should have been updated to remove the diuretic therapy focus and to accurately reflect the administration of Plavix instead of aspirin. The facility's policy requires the comprehensive care plan to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, and to include measurable objectives and timeframes based on the resident's needs as identified in the assessment. This process was not followed for the resident in question.