Failure to Revise Care Plans for Weight Loss and Pressure Ulcer
Penalty
Summary
The facility failed to update and revise care plans for two residents in accordance with their changing clinical conditions. For one resident with a history of stroke, diabetes, and dysphagia, the care plan was not updated to address significant weight loss identified during a quarterly Minimum Data Set (MDS) assessment. Although the resident was receiving a therapeutic diet and had interventions in place for diabetes management and resistance to care, the care plan did not reflect the newly identified weight loss. Staff interviews confirmed that the care plan should have been updated when the weight loss was triggered, but this was missed due to competing assessment demands. In a separate case, another resident with dementia and lower extremity contractures developed an unstageable pressure ulcer on the right foot, as documented in the Wound Management Report and observed during a facility visit. Despite the presence of the pressure ulcer and its documentation in the resident's records, there was no corresponding care plan in place to address this condition. Staff interviews revealed that the responsible nurse was aware of the pressure ulcer but failed to update the care plan, and both the DON and Administrator confirmed that the care plan should have been created for the management of the pressure ulcer.