Failure to Update Care Plans After Significant Changes and Events
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents following significant changes in their medical conditions and events. For one resident, after returning from a hospital stay with a new diagnosis of chronic kidney disease (CKD) stage 4 and an order for Furosemide, the care plan did not address the CKD diagnosis, nor were any goals or interventions related to this condition included. This omission occurred despite documentation in the resident's hospital records and active physician orders indicating the presence and management of CKD. For another resident, the care plan did not address a known allergy to lactose or a recent fall that resulted in injury. The resident had a documented mild intolerance to lactose and continued to receive dairy products, with no care plan interventions to prevent complications from this allergy. Additionally, after experiencing a fall that led to a hospital visit and documented injuries, the care plan was not updated to include goals or interventions to prevent future falls or injuries, despite the incident being discussed in risk management meetings. Interviews with facility staff, including the MDS nurse and DON, confirmed that these omissions were oversights and not in accordance with facility policy, which requires care plans to be updated following significant changes in condition, new diagnoses, or incidents such as falls. The facility's own policies emphasize the need for measurable objectives and timetables in care plans, as well as the inclusion of interventions based on comprehensive assessments and ongoing changes in residents' conditions.