Failure to Update Care Plans Following Changes in Resident Status and Interventions
Penalty
Summary
The facility failed to update and revise care plans to accurately reflect the current needs and interventions for three residents. For one resident with diagnoses including heart failure, renal insufficiency, diabetes mellitus, and hypertension, and who was admitted to hospice care, the care plan was not updated to reflect the hospice admission. Another resident with heart failure, renal insufficiency, peripheral vascular disease, and toxic liver disease experienced a fall, and although an intervention was documented in the progress notes, this intervention was not added to the care plan. A third resident with non-Alzheimer's dementia, diabetes mellitus, anxiety, and obesity experienced significant weight loss and had physician orders for daily blood sugar monitoring and diabetic medications with weight loss as a side effect, but the care plan was not updated to reflect these changes. Review of facility policy indicated that care plans are to be developed using an interdisciplinary team approach and must be updated to reflect the care currently required or provided for the resident, especially after significant changes in condition. Staff interviews confirmed that the expectation is for care plans to be updated when interventions or care needs change, but this was not done for the residents reviewed.