Failure to Update and Revise Care Plans Following Significant Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, to reflect the current condition of two residents. For one resident with a history of cerebral infarction, anxiety disorder, hemiplegia, and depression, the care plan did not include documentation of a hospitalization for suicidal ideation or a subsequent attempt to injure herself. Despite clear evidence in the medical record and psychiatric evaluation indicating the resident's risk for self-harm and recommendations for closer observation, the care plan was not updated to reflect these significant events or the recommended interventions. Another resident, diagnosed with Alzheimer's disease, dementia, high blood pressure, and anxiety disorder, experienced a significant decline and multiple falls. Although the resident was provided with a geriatric chair by hospice as a fall prevention measure after a hospital visit, this intervention was not added to the care plan. Staff interviews confirmed the use of the geriatric chair for fall prevention, but the care plan only reflected other interventions such as being up at the nurses’ station when anxious and scheduled care planning with family and hospice. The omission of the geriatric chair as an intervention was acknowledged by the MDS nurse, who could not provide a reason for its absence from the care plan. The facility’s policy required that care plans be reviewed and revised upon any status change, with the interdisciplinary team collaborating on intervention options and updating the care plan accordingly. However, in both cases, the care plans were not updated to reflect significant changes in the residents’ conditions or the interventions being used, as evidenced by record reviews, staff interviews, and direct observations.