Failure to Timely Update Care Plans After Resident Incidents
Penalty
Summary
The facility failed to review and revise care plans for two residents following significant changes in their conditions. For one resident with moderate cognitive impairment and multiple diagnoses, including stroke and dementia, a pressure area developed on the left great toe. Although interventions such as a blanket cradle and wound care were implemented, the resident's care plan and pocket care plan were not updated to reflect the removal of the air mattress or the new interventions for the toe wound. Observations and interviews confirmed that the care plan did not accurately reflect the resident's current needs or the interventions in place. Another resident, who had cognitive impairment and required setup for eating, sustained burns on the inner upper thighs after spilling hot coffee. The pocket care plan was updated to include the addition of ice cubes to coffee, but the main care plan was not revised to document the burn incident or the interventions trialed and refused by the resident. The care plan also did not include the family's responses to the incident. Staff interviews confirmed that the care plan should have been updated following the incident, and facility policy required individualized interventions for hot liquids to be noted in the care plan. Facility policies reviewed indicated that care plans should be updated after changes in condition and after each comprehensive review or quarterly assessment. Despite these policies, the care plans for both residents were not revised in a timely manner to reflect new interventions or changes in condition, as confirmed by staff and administrative interviews.