Failure to Update Care Plans Following Changes in Resident Condition and Orders
Penalty
Summary
The facility failed to update care plans in response to changes in resident conditions and physician orders for two residents. For one resident experiencing severe weight loss, documentation provided to the physician indicated poor appetite, use of nutritional supplements, and staff providing one-on-one assistance with meals. However, the resident's care plan was not updated to reflect the use of one-on-one feeding or nutritional supplements, despite staff interviews confirming these interventions were being provided and the resident was being monitored for nutrition risk due to weight loss. For another resident, physician orders indicated the removal of an indwelling catheter and new orders for bladder scans and as-needed straight catheterization following a voiding trial. The care plan for this resident continued to list risk for infection due to the indwelling catheter and was not updated to include the catheter removal or the new interventions. Staff interviews confirmed that care plans were expected to be updated as resident needs and physician orders changed, and facility policy required care plans to be reviewed and revised accordingly.