Failure to Revise and Update Comprehensive Care Plans
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for four residents, resulting in care plans that did not accurately reflect current physician orders, clinical events, or the residents' care needs. For one resident with multiple complex diagnoses and severely impaired cognition, the care plan was not updated to reflect a change to do not resuscitate (DNR) status, enrollment in hospice services, or a recent fall, despite these being documented in the clinical record and physician orders. The care plan continued to list the resident as full code and omitted significant changes in condition and care approach. Another resident's care plan was outdated and included interventions and equipment that were no longer applicable, such as the use of assistive bars for bed mobility and reminders to lock wheelchair brakes, even though the resident had been bedridden for years and no longer used a wheelchair. The care plan also referenced wound care for a non-existent wound and listed a mattress type that did not match current physician orders. Staff interviews confirmed a lack of awareness regarding these discrepancies and the removal of certain equipment. For two additional residents, care plans were not revised to include recent falls, injuries, or changes in seating systems. One resident's care plan failed to document a fall with injury and did not update the type of chair used, resulting in contradictory and outdated interventions. Another resident who sustained two falls, including one resulting in a hip fracture and surgical repair, had no documentation of these events or the resulting non-weight bearing status in the care plan. Staff interviews confirmed that care plans should have been updated following these significant changes, but the updates were missed.