Failure to Update and Revise Care Plans After Significant Resident Incidents
Penalty
Summary
The facility failed to update and revise care plans in response to significant events for two residents. For one resident with cerebral palsy, aphasia, and quadriplegia, the care plan did not include new interventions after the resident's father was observed altering the consistency of the resident's liquids and confronting staff about it. Despite this incident, there were no updates to the care plan to address the tampering of liquids, and the Director of Nursing acknowledged that best practice would be to update interventions following such incidents. For another resident with multiple diagnoses including achalasia, narcolepsy with cataplexy, anxiety disorder, PTSD, major depression, and bipolar disorder, the care plan identified the resident as a smoker and included interventions for managing smoking supplies. However, after the resident reported missing vapes and accused a staff member of taking them, and subsequently called the police, there was no evidence that the care plan was revised to address these new developments. Interviews with staff confirmed the resident's smoking status and use of vapes, but the care plan did not reflect updated interventions following the incident.