Failure to Revise Care Plans After Resident Condition Changes
Penalty
Summary
The facility failed to revise and update care plans for residents following significant changes in their condition, as evidenced by medical record reviews and staff interviews. For one resident who experienced a fall, the care plan was not updated to reflect the incident, and no fall-specific interventions were added or revised. The original care plan for this resident had not been updated since its initial creation several months prior, despite the occurrence of a fall that was documented in the nurse's notes. Another resident experienced multiple hospital transfers due to gastrostomy tube (G-tube) dislodgement and replacement, yet there was no documentation that a care plan addressing G-tube dislodgement and replacement was initiated or updated. Additionally, a third resident had a witnessed fall, but there was no evidence that the care plan was revised to address this event. Staff interviews confirmed that care plans are expected to be updated immediately following changes in a resident's condition, but this was not done for the residents reviewed.