Failure to Revise Care Plans After Incidents and Changes in Condition
Penalty
Summary
The facility failed to revise and update care plans for multiple residents following significant incidents and changes in condition. In one case, after a resident was found naked with another resident, the facility's investigation concluded that the care plan should be updated to reflect the resident's desire for companionship and require staff supervision to prevent sexual interactions due to cognitive deficits. However, review of the electronic health record showed that the care plan was not updated to include these specific interventions or goals. In another instance, a resident experienced a fall, but the care plan and physician orders were not revised to address the new risk or to implement additional fall prevention interventions after the incident. Additionally, the facility substantiated an incident of sexual abuse involving a resident, with the corrective action indicating that the care plan should be updated to monitor and supervise inappropriate sexual behaviors and assess the effects of medication changes. Despite this, the care plan for the resident was not revised to include interventions for monitoring or supervision of the inappropriate behaviors. Interviews with facility leadership confirmed that these care plan updates and interventions were not implemented as required.