Failure to Revise Care Plans After Changes in Resident Needs
Penalty
Summary
The facility failed to revise and update care plans for two residents following significant changes in their care needs. One resident, diagnosed with dementia, limited mobility, muscle weakness, and anxiety, was previously on hospice services and had a low air-loss mattress as part of her care plan. After being taken off hospice, her specialized mattress was removed and replaced with a standard pressure-reducing mattress. Despite this change, her care plan continued to reference the low air-loss mattress and did not reflect the updated intervention. Staff interviews confirmed that the care plan was not revised after the change in her bed and that care plans should be updated when resident needs change. Another resident, with diagnoses of dementia, anxiety, and depression, required staff assistance with mobility and had a physician's order for oxygen therapy as needed. However, the resident's care plan did not include any direction for nursing staff regarding oxygen therapy, despite the order being present in the medical record. Staff interviews revealed that direct care staff relied on report sheets and verbal instructions for oxygen administration, but acknowledged that such interventions should be included in the care plan for clarity and consistency. The facility's policy required that care plans be reviewed and updated to reflect changes in residents' goals and care needs. In both cases, the care plans were not revised in a timely manner to reflect significant changes in the residents' care, such as the discontinuation of hospice services and the initiation of oxygen therapy. This failure was confirmed through record review, staff interviews, and direct observation.