Failure to Update Resident Care Plan to Reflect Current Status
Penalty
Summary
The facility failed to review and revise the care plan for a resident to reflect the resident's current condition and care needs. The resident was admitted with diagnoses including cellulitis of the left lower leg, diabetes, and high blood pressure. The care plan included problems such as being on enhanced barrier precautions due to a PICC line and wounds, and receiving IV antibiotics for cellulitis. However, the clinical record showed that the PICC line was dislodged and removed, and the last dose of IV antibiotics was administered on a specific date, but the care plan was not updated to reflect these changes. Additionally, the care plan included a focus on C-Difficile infection, but the clinical record indicated that the resident's C-diff results were negative and isolation was discontinued. Despite a care plan meeting being held, the Director of Nursing confirmed that the care plans were not updated to accurately reflect the resident's current status and care needs. This failure was identified through review of facility policy, clinical records, and staff interview.