Failure to Timely Update Resident Care Plan After Changes in Condition and Orders
Penalty
Summary
The facility failed to review and revise the care plan for a resident following significant changes in the resident's condition and physician orders. Specifically, the resident had a change in code status from full code to do not resuscitate, but the care plan continued to reflect the previous status and was not updated at the time of the change. Additionally, the resident developed a pressure ulcer on the left lateral malleolus, which was not included in the care plan, despite physician orders for wound care. The care plan also continued to reference a PICC line after it had been discontinued, indicating that resolved conditions were not promptly removed from the care plan. These deficiencies were identified through facility policy review, clinical record review, and staff interviews. The Director of Nursing confirmed that the care plan was not updated when the resident's code status changed and that the pressure ulcer and PICC line status were not accurately reflected in the care plan until after the issues were identified. The Nursing Home Administrator also confirmed that the care plan should have been revised to reflect all changes in the resident's condition and treatment.