Failure to Revise Care Plans After Changes in Resident Condition
Penalty
Summary
Facility staff failed to review and revise person-centered care plans as residents' conditions changed, resulting in deficiencies for two residents. One resident, admitted after an acute hospital stay with diagnoses including chronic non-occlusive DVT and congestive heart failure, was assessed as having severely impaired cognitive abilities. Despite the development of a care plan addressing risk for impaired skin integrity, the plan was not updated to address a newly identified open area on the sacrum, which was later observed and assessed as a stage two sacral pressure ulcer. Another resident with multiple complex diagnoses, including dementia, severe protein calorie malnutrition, and total dependence for activities of daily living, experienced several skin issues such as skin tears, blisters, and open areas. Progress notes documented these changes, but the care plan was not revised to reflect the new injuries or pressure areas. Additionally, there was a lack of documentation showing immediate physician or responsible party notification of these changes in condition. The facility's policy requires that comprehensive care plans be prepared, reviewed, and revised by an interdisciplinary team after each comprehensive and quarterly MDS assessment, and that care plans include measurable objectives and time frames. However, the care plans for both residents were not updated in response to significant changes in their conditions, and required interdisciplinary team input was missing from at least one care plan meeting.