Failure to Revise and Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise and update care plans for two of eighteen residents to accurately reflect their current status, as required by facility policy and state regulations. For one resident with Alzheimer's, high blood pressure, and lumbar radiculopathy, the care plan did not include goals or interventions related to the resident's bed being placed against the wall, which created a physical restraint on one side. There was also no physician order for this intervention, and the care plan did not address this aspect of the resident's care. For another resident with non-Alzheimer's dementia, high blood pressure, and depression, the care plan indicated total dependence on staff for oral care. However, nursing progress notes documented that the resident was independent in oral care, and there was a lack of documentation regarding the provision and assistance level of personal hygiene services on multiple dates. Interviews with the resident and family confirmed that oral care was not provided daily or routinely. The DON and Nursing Home Administrator acknowledged the failure to update care plans for these residents.