Failure to Update Care Plans Following Changes in Resident Needs
Penalty
Summary
The facility failed to update and revise care plans in response to changes in residents' care needs, as required by policy. For one resident with COPD, congestive heart failure, and a history of repeated falls, a fall incident occurred when a quad-cane bent during a transfer, resulting in injury. Although the intervention was to replace the quad-cane with a hemi-walker, subsequent physical therapy documentation reflected the use of a hemi-walker, but the resident's care plan continued to list the quad-cane as the assistive device. The care plan was not updated to reflect the change in mobility aid, despite staff acknowledgment that the change had occurred after the fall. Another resident with acute respiratory failure and cellulitis of the lower limb had a physician's order for daily use of Tubi grips for edema management. Observations and weekly skin assessments documented severe edema and noncompliance with Tubi grips and foot elevation, but the care plan did not include the use of Tubi grips as an intervention. The Director of Nursing confirmed that the care plan should have included this intervention but did not. These failures to update care plans placed residents at risk of not receiving appropriate care as their needs changed.