Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
The facility failed to revise the care plan for a resident following a significant change in condition. The resident, who had diagnoses including Alzheimer's disease, congestive heart failure, osteoarthritis, and diabetes mellitus, was previously assessed as having intact cognition and required extensive assistance from one staff member for transfers, toileting, and bed mobility. After experiencing increased weakness and falls, the resident was evaluated in the emergency department, where a fractured left ankle was diagnosed and splinted. Upon return to the facility, the resident became non-weight bearing and required the use of a Hoyer mechanical lift with assistance from two staff members for all transfers. Despite this change in the resident's condition and care needs, the care plan was not updated to reflect the new requirement for total assist by two staff using a mechanical lift. Observations and staff interviews confirmed that the resident's transfer method had changed due to the fracture, but the care plan continued to indicate the need for only one staff assist and a walker for ambulation. The assistant director of nursing acknowledged that the care plan had not been revised to address the resident's current needs following the injury.