Failure to Timely Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to ensure timely review and revision of care plans for two residents following significant changes in their conditions and treatments. For one resident with a history of stroke, dysphagia, muscle weakness, and epilepsy, the care plan was not updated after a fall from a recliner, despite a post-fall assessment and identification of the root cause and new intervention. The care plan had last been revised prior to the fall, and staff confirmed that the necessary updates to fall prevention interventions were not made after the incident and interdisciplinary review. For another resident with multiple chronic conditions, including congestive heart failure, diabetes, chronic kidney disease, and severe depression, the care plan did not reflect recent medication changes, such as the initiation of new antidepressant and anticoagulant therapies. The care plan was last revised before these medication orders were implemented. Facility policy requires care plans to be updated on an ongoing basis as needed, especially following significant changes, but this was not done for either resident.