Failure to Timely Review and Revise Resident Care Plans
Penalty
Summary
The facility failed to review and revise the care plans for five out of thirteen residents as required by policy and federal regulations. The care plans were not updated to reflect significant changes in residents' conditions or treatments. For example, one resident was admitted to hospice care, but the care plan was not updated to include hospice services. Another resident no longer required a sling or extensive assistance with transfers, yet the care plan still listed these interventions. Additionally, a resident's care plan included an active urinary tract infection, although the resident no longer had this condition. Further deficiencies were observed with residents whose care plans did not reflect current medication regimens or physical needs. One resident's care plan indicated a risk for adverse effects from antianxiety medication, despite the resident no longer receiving such medication. Another resident's care plan continued to list the use of a cervical collar, even though physician orders and progress notes indicated the collar had been discontinued following a surgical evaluation. Interviews with the DON confirmed that care plans should be updated promptly to reflect changes in residents' conditions, treatments, and physician orders. However, the care plans for these residents were not revised in a timely manner, resulting in discrepancies between the documented plan of care and the residents' actual needs and treatments.