Failure to Timely Revise Care Plans After Resident Status Changes
Penalty
Summary
The facility failed to ensure that care plans were promptly and accurately revised following significant changes in the condition or care needs of two residents. For one resident with dementia, atrial fibrillation, and a recent right humerus fracture, the mobility care plan was not updated after therapy changed the resident's transfer status from a two-person assist to a one-person assist with a wheeled walker. Despite therapy's recommendation being documented, the care plan continued to reflect the original intervention, and this discrepancy was identified after the resident experienced a fall during a transfer with staff assistance. Another resident with Alzheimer's, dementia, and severe malnutrition developed a stage 2 pressure injury to the right heel. Although nursing staff documented the injury and new interventions were ordered, the resident's care plan was not revised to include these interventions until several weeks later. The care plan was only updated after a significant delay, despite the facility's policy requiring care plan revisions upon status changes. The delay in updating the care plan meant that the interventions for the pressure injury were not reflected in the resident's official care plan documentation in a timely manner. Interviews with facility staff confirmed that care plan revisions were not completed immediately following changes in resident status, and that updates to task sheets did not automatically update the care plan. The surveyor was unable to locate documentation of the interventions in the resident's CNA Kardex or determine when certain interventions were initiated, further highlighting the lack of timely care plan updates.