Failure to Revise Care Plan Following Change in Resident Status
Penalty
Summary
Facility B failed to review and revise the care plan for one of four residents reviewed for care planning. Specifically, a resident who had previously been treated for pressure ulcers and was on a low air loss mattress had since healed and no longer had any wounds or pressure ulcers, as confirmed by a weekly skin assessment and staff interviews. Despite these changes, the resident's care plan continued to reference the presence of skin injuries, the use of a low air loss mattress, and indicated that the resident required assistance with eating by mouth, even though the resident was NPO and receiving tube feedings per physician orders. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the care plan did not accurately reflect the resident's current status. The care plan was not updated to remove references to healed wounds, the discontinued use of a low air loss mattress, or the resident's current nutritional status. This lack of timely review and revision of the care plan was inconsistent with the facility's own policy, which requires care plans to be updated to reflect changes in a resident's condition.