Failure to Update Resident Care Plan to Reflect Physician Orders
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated and revised to accurately reflect the resident's specific care needs. According to facility policy, resident care management should be conducted systematically by an interdisciplinary team and be consistent with the medical plan of care, including physician orders. For one resident, the clinical record showed a physician order for assist of one person with transfers, but the care plan documented a requirement for assistance of two persons with transfers. This discrepancy was identified during a review of the resident's records and care plan. Interviews with facility staff confirmed the inconsistency. The Registered Nurses Assessment Coordinator (RNAC) acknowledged that the care plan did not match the physician's order and stated that changes in care needs were not always communicated to them by nursing staff. The Director of Nursing also confirmed that the care plan was not revised to reflect the resident's current needs as required by facility policy and regulations.