Failure to Update Care Plan After Resident Injury
Penalty
Summary
Facility staff failed to revise the interdisciplinary care plan to accurately reflect interventions for a resident who sustained bruises of unknown origin. The resident was found to have bruises on both arms, which, after investigation, were determined to be caused by the resident's arms coming into contact with wheelchair brake extenders while self-propelling. The initial evaluation indicated the resident required assistance but was able to self-propel the wheelchair, and a subsequent therapist assessment confirmed that self-propelling with an extended brake was beneficial for the resident. Despite documenting the incident and the therapist's findings in progress notes, the facility did not update the resident's care plan to address the risk of bruising from the wheelchair brake extenders. During interviews, facility leadership confirmed that while interventions were documented in progress notes, they were not incorporated into the care plan. This omission resulted in the care plan not reflecting the resident's current risk factors and necessary interventions following the incident.