Failure to Update Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to update and revise individualized and comprehensive care plans for two residents following significant changes in their conditions. For one resident with dementia, the care plan was not updated to reflect the resident's increased time spent in bed and the importance of maintaining a fully charged personal cellphone at bedside to support psychosocial well-being and facilitate communication with family members. The care plan also did not address the resident's cultural background or the need for individualized, person-centered care, despite observations and staff interviews indicating these needs. For another resident with end stage renal disease (ESRD) on hemodialysis (HD), the care plan was not revised after the resident's HD schedule increased from three to four times per week. The care plan continued to reflect the previous schedule and did not account for the change in treatment frequency, as confirmed by the DON during record review. The facility's policy required care plans to be reviewed and updated every 90 days or when there is a change in resident status or condition, but this was not followed in these cases.