Failure to Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised to accurately reflect the current care and treatment needs of residents. For one resident with a history of acute renal failure, the care plan continued to include interventions for diuretic therapy nearly a year after the medication had been discontinued, as confirmed by the DON. This discrepancy was identified through a review of the resident's medical record, care plan, and physician orders, which showed no active diuretic order since the previous year. Additionally, another resident's care plan included an intervention for a visual cue (sign) to remind the resident to use the call light for assistance, despite staff and social services confirming that the resident found the sign demeaning and it was supposed to have been removed from the care plan. In a third case, a resident with a physician's order for a left arm sling for pain and swelling did not have this intervention reflected in the care plan. These findings were based on record reviews, staff interviews, and direct observation, demonstrating a failure to keep care plans updated and consistent with current physician orders and resident needs.