Failure to Update Care Plans Following Changes in Resident Status and Physician Orders
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect the current care needs of five residents. According to the facility's policy, care plans must be evaluated at least every 90 days, annually, and whenever there is a significant change in a resident's condition, including after hospital stays or incidents. However, clinical record reviews and staff interviews revealed that care plans were not consistently updated following changes in physician orders or resident status. For example, one resident was initially placed on transmission-based precautions for VRE of the urine, but after the precautions were discontinued by physician order, the care plan was not revised to reflect this change. Similarly, another resident was placed on droplet precautions for influenza, but the care plan was not updated after the precautions were discontinued. In another case, a resident was prescribed an antipsychotic medication, but the care plan did not include this new medication. Additionally, a resident receiving oxygen therapy had a care plan that did not match the current physician orders regarding oxygen flow rate and target oxygen saturation. Finally, a resident's care plan continued to indicate a two-person assist for transfers, despite a physician order changing the requirement to a one-person assist. These deficiencies were confirmed through interviews with the Quality Assurance and Performance Improvement Registered Nurse, who acknowledged that the care plans had not been revised to reflect the most current orders or resident needs. The lack of timely updates to care plans resulted in discrepancies between the care being provided and the documented care plans for these residents.