Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to accurately reflect the current care needs of two residents. For one resident with a history of stroke who was cognitively intact and required assistance with daily care, the care plan indicated the need for intermittent straight catheterization, despite a physician's order for an indwelling Foley catheter for urinary retention. The resident confirmed the presence of an indwelling catheter, and the Assistant Director of Nursing acknowledged that the care plan had not been revised to reflect this change. For another resident with a history of hip fracture and diabetes, the care plan included interventions for anticoagulant therapy with Lovenox and insulin administration. However, a review of the Medication Administration Record for two consecutive months showed no evidence that the resident received either medication. The Director of Nursing confirmed that the resident was no longer receiving Lovenox or insulin and that the care plan should have been updated to reflect this change.