Failure to Timely Update and Communicate Care Plan Interventions
Penalty
Summary
The facility failed to update and communicate a resident's care plan following an incident involving increased behavioral symptoms and rejection of care. The resident, who had multiple mental health diagnoses including schizophrenia, bipolar disorder, major depressive disorder, intellectual disability, anxiety, and hallucinations, exhibited moderate cognitive impairment and required extensive assistance with toileting due to frequent incontinence. The care plan, which was not revised until several days after the incident, instructed staff to provide care in pairs due to the resident's tendency to make false accusations and behavioral issues. However, staff interviews revealed inconsistent awareness and implementation of this intervention, with some staff unaware of the requirement to provide care in pairs and others stating it was not always practiced. Observations confirmed that care was provided by a single staff member despite the care plan's directive. The administrative nurse acknowledged that the care plan had not been reviewed and revised to include the paired care instruction until after the incident occurred. The facility's policy required care plans to be reviewed and revised with any new interventions, but this was not followed in a timely manner, resulting in uncommunicated care needs and a risk for inadequate care.