Failure to Review and Revise Care Plans After Change in Condition
Penalty
Summary
Facility staff failed to review and revise the care plans for two residents following significant changes in their conditions. For one resident who experienced a fall, the care plan was not updated to include the new intervention of fall mats, despite documentation in the clinical record that fall mats were implemented after the incident. Observations confirmed that fall mats were not present at the bedside during subsequent checks, and staff interviews revealed a lack of awareness regarding the need for this intervention. The director of nursing acknowledged that the care plan should have been reviewed and revised after the fall, as it provides essential guidance for staff care. In another case, a resident with paraplegia and other significant diagnoses was care planned for fall prevention with interventions such as ensuring the resident wore shoes when ambulating. However, the resident was dependent for bed mobility and transfers, did not ambulate, and used a wheelchair. Staff interviews confirmed that the care plan did not accurately reflect the resident's needs, as the intervention to ensure the resident wore shoes when ambulating was not appropriate for someone who could not walk. The care plan was not revised to reflect the resident's actual functional status. Facility policy required care plans to be updated as changes occurred and reviewed quarterly, but documentation and staff interviews indicated that these requirements were not met for the two residents. The deficiencies were identified through observation, staff interviews, facility document review, and clinical record review, and were communicated to facility leadership during the survey.