Care Plan Not Updated for Resident's Menstrual-Related Nausea and Vomiting
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a female resident with a history of hypoglycemia, bipolar disorder, and type 2 diabetes mellitus was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly reviews. Specifically, the care plan did not include information regarding the resident's uncontrollable nausea and vomiting during her menstrual cycles, despite this being a recurring issue noted by both nursing and medical staff. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and there was a standing order for Zofran to address her symptoms. Interviews with facility staff, including an LVN, a nurse practitioner, and the DON, confirmed that the resident experienced frequent uncontrollable nausea and vomiting during her menstrual cycle, and that this should have been documented in her care plan. The absence of this information in the care plan meant that other staff might not be aware of the resident's symptoms, potentially leading to misdiagnosis. Additionally, when requested, the facility was unable to provide a policy on updating care plans prior to the survey team's exit.