Failure to Update Care Plan Following Discontinued Pressure Ulcer Intervention
Penalty
Summary
The facility failed to update the care plan for a resident with pressure ulcer interventions after a significant change in condition. The resident, who was cognitively intact and had diagnoses including osteoporosis, thyroid disorder, malnutrition, and depression, had an order for Arginaid Oral Packet to aid with wound healing, which was discontinued in August 2024. However, the care plan, last reviewed in April 2025, still listed the discontinued supplement as an active intervention. Interviews with staff revealed that care plan updates were typically done the same day or as soon as possible after changes, but there was no set schedule. The director of nursing confirmed that care plans should be updated at least quarterly and with any change of condition, and acknowledged that the care plan should have been updated when the order was discontinued. The facility was unable to provide a policy regarding care plan updates.