Failure to Update Care Plan for Change in Condition
Penalty
Summary
The facility failed to develop and implement a care plan that addressed a resident's change in condition, specifically episodes of nausea, vomiting, diarrhea, and increased generalized weakness. Despite documentation in the medical record of multiple episodes of these symptoms and the administration of non-pharmacological interventions and medication as ordered by the physician, there was no evidence that a care plan was created or updated to reflect these changes. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and revised as residents' conditions change, but this was not followed in this case. Interviews with facility staff, including an LVN and the DON, confirmed that a care plan should have been developed in response to the resident's change in condition, and both verified that no such care plan was present in the medical record. The resident involved had severe cognitive impairment and experienced multiple documented episodes of gastrointestinal symptoms and increased weakness, yet the care plan was not updated to address these needs.