Failure to Timely Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to ensure that residents' care plans were revised and updated in a timely manner, as required. For one resident who experienced a fall while attempting to transfer from the toilet to a wheelchair, the care plan did not reflect the actual fall or include any new interventions following the incident. Although the resident had a care plan indicating risk for falls, no updates or additional interventions were added after the fall occurred, and the care plan was only updated after surveyor intervention. Another resident had a physician order for an indwelling Foley catheter due to urinary retention, but there was no corresponding care plan addressing the catheter. The lack of a care plan for the Foley catheter was confirmed during record review and acknowledged by the RN MDS Coordinator. Both deficiencies were substantiated through observation, interviews, and record review, and were acknowledged by facility leadership.