Failure to Update Care Plans Following Changes in Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated or revised to reflect the current care needs of two residents. For one resident with muscular dystrophy and limited lower extremity range of motion, the care plan included the use of bilateral PRAFO boots with specific instructions for their application and removal. However, multiple observations revealed that the resident was not wearing the boots, and both the resident and therapy manager confirmed that the boots had been discontinued about one to two months prior due to discomfort and the resident's refusal to wear them. Despite this, the care plan was not revised to reflect the discontinuation of the PRAFO boots. For another resident who was cognitively intact and required maximum assistance for care, the care plan indicated frequent urinary tract infections and directed staff to monitor and record urinary output. Nursing documentation showed that the resident's indwelling urinary catheter had been removed and that she was now incontinent of urine. There was no evidence that the care plan was updated to reflect the change in urinary status or to revise interventions accordingly. The Director of Nursing confirmed that the care plan should not have included instructions to monitor urine output after the catheter was removed.