Failure to Timely Update Care Plans with Physician-Ordered Interventions
Penalty
Summary
The facility failed to make timely revisions to the comprehensive care plans for two residents, resulting in staff not having all necessary information to address the residents' needs. For one resident, who had a history of chronic obstructive pulmonary disease, stroke, dysphasia, dementia, diabetes, and anemia, and was incontinent with a feeding tube, provider orders indicated the use of GERI sleeves on both arms to protect fragile skin. Despite documentation of open wounds on her arms due to scratching and an order for protective sleeves, the care plan was not updated to include this intervention. For another resident with Parkinson's disease, provider orders required the use of a Prevalon Boot on the right ankle/foot to prevent skin breakdown due to foot rotation causing pressure on the ankle. The care plan did not reflect this intervention, and during observation, the resident was found not wearing the boot, with a small area of redness noted on the ankle. The nurse confirmed the omission in the care plan and subsequently applied the boot. These omissions in care plan updates were identified through observation, interview, and medical record review.