Failure to Revise Care Plans for Significant Changes and Critical Information
Penalty
Summary
The facility failed to revise and update care plans to reflect significant changes and critical information for several residents. For one resident with hemiplegia, dysphagia, and chronic pain syndrome, there was documented significant weight loss over a short period, but the care plan did not address this weight loss or provide direction for intervention, despite facility policy requiring individualized interventions for nutritional risk. The Director of Nursing confirmed that care plans should address significant weight losses and that staff should notify the physician and complete weights as ordered. Another resident with hemiplegia, morbid obesity, and a history of traumatic brain injury was involved in an incident where they propelled their wheelchair into another resident, causing a fall. The care plan included some interventions for wheelchair mobility and spatial awareness, but lacked additional safety interventions to ensure the safety of the resident and others. The DON acknowledged that if staff believed a resident was unsafe in a wheelchair, appropriate interventions should be included in the care plan. Additional deficiencies included a resident whose care plan did not reflect a change in advanced directive status from full code to DNR, despite documentation in nursing notes and family confirmation. Another resident with severe allergies to food, environmental factors, and medications had no care plan focus area or interventions addressing these allergies, nor documentation of a self-medication assessment or the location of their EpiPen, despite orders allowing self-administration. These omissions were contrary to facility policy and best practices for comprehensive, individualized care planning.