Failure to Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to review and revise the care plans for two residents as required by both facility policy and federal regulations. For one resident with chronic kidney disease and chronic diastolic congestive heart failure, there were conflicting fluid restriction interventions documented in the care plan: one section listed a restriction of 1500 ml per 24 hours, while another listed 2000 ml per 24 hours. The care plan was not updated to reflect the most current physician order for fluid restriction, and the Director of Nursing confirmed that the care plan should have been revised when the fluid restriction order changed. For another resident with Parkinson's Disease, a history of repeated falls, and lumbar compression fractures, the care plan did not include a new fracture sustained after a recent fall and subsequent hospital transfer. Additionally, the care plan still included an intervention for a urinary tract infection (UTI) that was no longer current, as there was no documentation of ongoing treatment for a UTI. The Nursing Home Administrator confirmed that the new fracture was not added to the care plan and that the resolved UTI was not promptly removed.