Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to revise and update care plans to reflect the current care needs of two residents. For one resident with severe cognitive deficits and multiple diagnoses, the care plan continued to indicate the presence of a Foley catheter and related enhanced barrier precautions, despite staff observations and interviews confirming that the resident did not have a Foley catheter. Nursing assistants providing care were unaware of any history of a Foley catheter for this resident, and no catheter was observed during care. For another resident with intact cognition and multiple complex medical conditions, including end stage renal disease and a history of lung transplant, the care plan listed an outdated dialysis transportation schedule. The resident reported, and staff confirmed, that the actual pick-up time for dialysis had changed months prior, but the care plan was not updated to reflect this. The consulting nurse acknowledged that both care plans did not accurately represent the residents' current care needs, and the facility's policy requires individualized and current care plans prepared by the interdisciplinary team.