Failure to Revise Care Plans for Residents with Significant Diagnoses
Penalty
Summary
The facility failed to revise and update care plans for two of eight sampled residents, as required following comprehensive assessments. For one resident with a history of severe cognitive impairment, cerebral vascular accident (CVA), transient ischemic attack (TIA), and Parkinson's disease, the care plan did not address concerns related to CVA or TIA. Despite documented incidents where the resident was unable to sit up and eat, and later required emergency transfer to the hospital for a suspected stroke and was found to have a pulmonary embolism, these diagnoses were not included in the care plan. The MDS coordinator stated that these conditions were omitted because they were not considered active diagnoses at the time. For another resident with diagnoses including diabetes, heart failure, hypertension, angina pectoris, and end stage renal disease, the care plan did not address angina pectoris or heart failure, despite a physician's order for a nitroglycerin patch for angina. The CAA worksheet identified congestive heart failure and angina as concerns, but these were not reflected in the care plan. The resident later complained of chest pain and was subsequently found unresponsive in bed. The MDS coordinator acknowledged that the nitroglycerin patch and related diagnosis had been overlooked and should have been included in the care plan.