Failure to Update Care Plans After Significant Change in Condition
Penalty
Summary
The facility failed to ensure that care plans for two residents were updated to reflect their current care needs following significant changes in their conditions. One resident, who had diagnoses including Alzheimer's disease, COPD, hemiparesis, and anxiety, was dependent on staff for all activities of daily living and had a Stage 2 pressure ulcer. Despite being on hospice and requiring Enhanced Barrier Precautions (EBP) due to an open area, the care plan did not include interventions or directions for staff regarding the use of personal protective equipment (PPE) necessary for infection control. Staff interviews revealed a lack of awareness about the resident's EBP status, and care was provided without appropriate PPE, as confirmed by both nursing and administrative staff. Another resident, with diagnoses of paraplegia, hypertension, pressure ulcer, and osteomyelitis, experienced a significant change in condition after a hospital stay and was placed on hospice services. The resident's Minimum Data Set (MDS) indicated increased dependence on staff for activities of daily living, but the care plan was not revised to reflect these changes. The care plan continued to document previous levels of independence and did not address the resident's current needs for assistance, despite the resident now requiring more substantial support and the use of a mechanical lift with two staff members for transfers. Facility policy required that comprehensive, person-centered care plans be developed and updated within specific timeframes following significant changes in a resident's condition, including after hospital readmission and at least quarterly. In both cases, the care plans were not updated as required, resulting in a lack of clear guidance for staff and the potential for delayed or missed care.