Failure to Timely Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to update or revise care plans for two residents following significant changes in their conditions or treatments. For one resident with a history of bipolar disorder, lower back pain, and vertebral fractures, the care plan was not updated in a timely manner after a fall incident. The fall occurred on 8/8/2025, but the care plan was not revised to include new interventions until 9/3/2025. The MDS Coordinator confirmed that interventions should have been added the next working day, but this did not occur. For another resident with anxiety, delusions, depression, and dementia, the care plan continued to include interventions related to diuretic and psychotropic medications even after these medications had been discontinued as of 7/16/2025. The care plan was not revised to reflect this significant change in the resident's medication regimen. The MDS Coordinator confirmed that the care plan should have been updated to reflect the discontinuation of these medications.