Failure to Update Care Plans After Resident Injury and Smoking Behavior
Penalty
Summary
Facility staff failed to review and revise comprehensive care plans for two residents following significant changes in their conditions and behaviors. For one resident with moderate cognitive impairment, staff documented a burn injury to the right thigh caused by a coffee spill, with subsequent treatment and physician notification. However, the care plan was not updated to include interventions for hot liquids or burn treatment. Interviews with the ADON, DON, and Care Plan Coordinator revealed that the incident was not communicated to the interdisciplinary team (IDT), and the care plan was not revised as required by facility policy. For another resident, also assessed with moderate cognitive impairment and a history of smoking, staff documented the resident's participation in scheduled smoke breaks. Despite this, the care plan did not include interventions related to smoking. The Care Plan Coordinator acknowledged missing the addition of smoking interventions during the quarterly care plan update. Staff interviews confirmed that care plans are expected to be updated by any nurse or IDT member following changes in a resident's condition or behavior, but this process was not followed in these cases.