Failure to Update Care Plan After Change in Condition
Penalty
Summary
The facility failed to revise a resident's Comprehensive Care Plan to include measurable, resident-specific interventions following a change in condition involving right-eye redness, which led to the initiation of ciprofloxacin ophthalmic drops. Although the physician ordered antibiotic eye drops for the resident's right-eye redness, the care plan was not updated to reflect this new condition or the associated treatment. The last update to the care plan addressed a previous influenza-related infection and did not include any documentation or interventions related to the resident's current eye condition. There were also no nursing progress notes, assessments, or physician assessments documenting the necessity for the eye drops until several days after the order was initiated. Interviews with facility staff revealed that the responsibility for updating care plans was unclear during the period when the deficiency occurred, as there was no charge nurse assigned to the unit at the time. The Assistant Director of Nursing and the Director of Nursing both stated that care plans should be updated with any change in condition, but acknowledged that the absence of a charge nurse contributed to the failure to revise the care plan. The Regional Director of Nursing and a Registered Nurse Supervisor confirmed that the resident's change in condition and new treatment should have resulted in updated care plan interventions, but this was not completed.