Failure to Revise Care Plans with Current Resident Information
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information for two residents. For one resident, physician's orders indicated changes in wound care, antibiotic therapy, and isolation precautions over several months. However, the care plan was not updated to show that the wound had healed, antibiotic therapy had ended, and isolation precautions were discontinued. Both the wound care nurse and the DON confirmed that the care plan still included outdated interventions and should have been revised when the resident's condition and treatment changed. For another resident, physician's orders required the use of compression stockings for pitting edema, specifying when they should be applied and removed. Despite these orders, the care plan did not document the use of compression stockings or related interventions. The DON acknowledged that these interventions should have been included in the care plan to ensure care was provided as ordered.