Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to accurately reflect the current care needs of two residents. For one resident, multiple care plans indicated the presence of a stage three pressure ulcer, use of intravenous fluids, a midline intravenous catheter, administration of oral vancomycin, and the need for contact precautions. However, a review of the resident's clinical record, including the Medication Administration Record and physician's orders, showed no evidence that the resident had an active stage three pressure ulcer, was receiving intravenous fluids, had a midline catheter, was taking oral vancomycin, or was on contact precautions. The Director of Nursing confirmed that the care plans should have been updated to reflect the resident's current status. For another resident, the care plan documented that the individual was receiving intravenous antibiotics for sepsis and an ESBL infection and was on contact precautions. Review of the clinical record, including the Medication Administration Record and physician's orders, revealed no evidence that the resident was receiving intravenous antibiotics for sepsis/ESBL infection or required contact precautions. The Director of Nursing confirmed that the care plan should have been updated to reflect the resident's current care needs. These findings indicate that the facility did not revise care plans as required when residents' conditions changed.