Failure to Update Care Plans After Significant Changes and Incidents
Penalty
Summary
The facility failed to ensure that care plans were updated and revised in accordance with their own policies for three residents. For one resident with multiple diagnoses including rhabdomyolysis, orthostatic hypotension, and muscle weakness, the care plan was not updated after the resident experienced an unwitnessed fall that resulted in a head injury and required evaluation at the emergency department. The care plan, dated prior to the fall, did not reflect the incident or any new fall prevention interventions, and the electronic medical record did not document any updates related to fall prevention. Another resident with diagnoses such as congestive heart failure, COPD, hypertension, and diabetes was not care planned for new oxygen use or for weight loss interventions after a supplement was ordered. Additionally, a third resident with a history of traumatic brain injury, Parkinson's disease, and other complex conditions experienced a fall resulting in a black eye, but the incident was not included in the care plan. Staff interviews confirmed that care plan updates were the responsibility of clinical managers, nursing staff, DON, and MDS staff, but these updates were not consistently made following significant changes in condition or incidents.