Failure to Update Care Plan After Change in Resident's Condition
Penalty
Summary
The facility failed to update a resident's care plan to reflect changes in the resident's care needs following a significant medical event. Specifically, a resident with a history of heart failure and Alzheimer's disease, who was moderately cognitively impaired and required supervision for showering and bathing, experienced a fall at his daughter's home that resulted in a brain bleed and the placement of five sutures in the back of his head. The care plan was updated to include monitoring of the staples to the head and instructions to notify the medical provider if the condition worsened. However, after the staples were removed, the care plan was not revised to discontinue the intervention related to staple care. Observations confirmed that the resident no longer had staples, and staff interviews verified that the care plan should have been updated to reflect this change. The facility's policy required proper documentation in the care plan for discontinued interventions, but this was not completed for this resident.