Failure to Update Comprehensive Care Plans with Current Medical Orders
Penalty
Summary
The facility failed to fully develop and revise person-centered comprehensive care plans to address the individualized needs of two residents. For one resident with diagnoses including congestive heart failure and diabetes, the clinical record showed recent physician orders for both short-acting and long-acting insulin, as well as a specific daily fluid restriction. However, the resident's comprehensive care plan, last revised after these orders were issued, did not reflect these updated medical treatments and interventions. Similarly, another resident with hypertension and hypoxemia had a physician's order for oxygen therapy due to shortness of breath. Despite this, the resident's comprehensive care plan, last revised after the order, did not include the updated intervention. These findings were confirmed through clinical record reviews and staff interviews, indicating that the facility did not ensure care plans were updated to reflect current physician orders and resident needs.