Failure to Update and Clarify Resident Care Plans
Penalty
Summary
The facility failed to update and clarify care plans for two residents following changes in their clinical status. For one resident, an order for Lovenox, an anticoagulant, was discontinued, but the care plan continued to reference anticoagulant use and associated interventions, such as monitoring for bleeding and providing education on anticoagulant risks. The care plan was not revised to reflect the discontinuation of the medication, and the Administrator confirmed that there was no current order for the anticoagulant at the time of review. For another resident, the care plan lacked clarity regarding the level of assistance required for activities of daily living (ADLs). The care plan stated that either all effort was provided by a helper or that two or more helpers assisted, but interviews with MDS nurses revealed that the level of assistance could fluctuate depending on the resident's cooperation. There was no clear guidance for nursing assistants on when to use one or two-person assistance, and the Administrator acknowledged this lack of clarity.