Failure to Review and Revise Resident Care Plans After Changes in Condition
Penalty
Summary
The facility failed to review and revise care plans for three residents following significant changes in their conditions or care needs. For one resident, the care plan continued to document the presence of an indwelling urinary catheter and related interventions, despite physician orders for catheter removal and multiple observations confirming the absence of a catheter. Staff interviews confirmed that the care plan was not updated to reflect the resident's current status. Another resident experienced multiple unwitnessed falls over several months, with nursing progress notes lacking documentation of contributing factors or any new interventions implemented after each fall. The care plan did not reflect all falls or show updates with new interventions following these incidents. A third resident's care plan failed to indicate the resolution of a urinary tract infection after completion of antibiotic therapy, despite physician orders and medication administration records confirming treatment. In each case, staff were unable to explain why care plans were not revised to reflect current conditions and interventions.