Failure to Revise Care Plans After Significant Status Changes
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for two residents following significant changes in their medical conditions. For one resident, who had a complex medical history including respiratory failure, COPD, neuromuscular bladder dysfunction, and dependence on a ventilator, the care plan did not reflect the presence of a suprapubic catheter after a physician order was made for a urethral indwelling catheter. Despite documentation in progress notes and direct observation confirming the presence of a suprapubic catheter, the care plan continued to address only urinary incontinence and not the catheter. For another resident, who was dependent on staff for all activities of daily living and had severe contractures due to multiple diagnoses such as anoxic brain injury, sepsis, and persistent vegetative state, the care plan did not include interventions for contractures. Medical records and staff interviews confirmed the presence and severity of the contractures, but the care plan was not updated to address this condition until it was identified during the survey process. The facility's policy required care plans to be reviewed and revised upon any change in resident status, with the MDS Coordinator and interdisciplinary team responsible for updating interventions. However, in both cases, the care plans were not revised in a timely manner to reflect the residents' current needs, as evidenced by the lack of documentation and care plan updates for the suprapubic catheter and contractures.