Failure to Revise Care Plans After Significant Changes in Condition
Penalty
Summary
The facility failed to revise and update the comprehensive person-centered care plans for two residents following significant changes in their conditions. One resident, who had a history of recurrent falls, sustained a major injury—a left femur fracture—after an unwitnessed fall. Upon readmission following surgery, the facility did not develop or document new interventions in the care plan, despite the incident report listing additional measures such as bed in lowest position, fall mat, clip alarm, and bed sensor alarm. The care plan continued to reflect only the standard interventions that were already in place prior to the injury. As a result, the resident experienced two more unwitnessed falls before discharge. The facility's own Fall Prevention Policy required nursing to review and update the care plan after a fall, which was not done in this case. Another resident with an indwelling urinary catheter did not have their care plan revised to include catheter care after the device was reinserted. Although physician orders specified catheter care every shift, and the resident had the catheter for over a month, the care plan was not updated to reflect this need. Both the RN and DON confirmed that the care plan should have been revised to include catheter care, as it is essential for reflecting the resident's current needs and ensuring appropriate interventions. The facility's policy on care plans also required changes to be made as necessary following significant changes in condition or needs, which was not followed.