Failure to Revise Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to revise the care plans for two residents following documented changes in their care needs. One resident, admitted with acute respiratory failure and COPD, was observed self-administering an Albuterol inhaler multiple times daily. Despite a physician's order allowing the inhaler at bedside and specifying its use as needed, the care plan did not include any assessment or monitoring of the resident's self-administration, nor did it outline staff responsibilities for monitoring or documentation related to the inhaler. Another resident, admitted with a fracture and a history of repeated falls, had a urinary catheter inserted upon admission. The resident developed signs of a urinary tract infection (UTI), including cloudy, foul-smelling urine and an elevated white blood cell count, which led to laboratory testing and the initiation of antibiotic therapy. However, the care plan was not updated to reflect the new diagnosis of UTI or the administration of antibiotics. The facility's policy requires care plans to be revised as residents' conditions change, but this was not done in either case.