Failure to Revise Care Plans Following Changes in Resident Condition and Physician Orders
Penalty
Summary
The facility failed to revise and update care plans for two residents following changes in their conditions and physician orders. For one resident, observation revealed that a wrist splint, ordered by the physician to be applied each morning and removed in the evening, was not addressed in the resident's care plan. The Director of Nursing confirmed that the intervention for the wrist splint had not been added to the care plan, despite the standing physician order. For another resident, a review of the medical record showed that the resident experienced a fall, but the care plan was not updated to include new interventions following the incident. The Director of Nursing confirmed that the care plan had not been revised after the fall, and the facility's policy requires care plans to be updated as residents' conditions change and to implement additional interventions if falls recur. These findings indicate that the facility did not ensure care plans were revised in accordance with changes in residents' needs and physician directives.