Failure to Update Care Plans After Incidents and Allegations
Penalty
Summary
The facility failed to update or revise care plans for three residents following significant incidents or allegations, as required by policy. For one resident, visible bruising over the bridge of the nose and both eyes was observed, but the care plan was not updated to reflect this new condition, despite the resident's history of wandering, falls, and anticoagulant therapy. Another resident made an allegation of sexual abuse, which led to an investigation and subsequent treatment for a urinary tract infection, but the care plan was not revised to address the new allegation or related behavioral changes. A third resident was noted to have bruising on the right jawline after being suctioned, yet there was no care plan addressing this injury. These deficiencies were identified through observation, record review, and interviews. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change, but this was not followed in the cases reviewed. The lack of timely care plan updates after incidents or allegations was confirmed by the administrator during the survey.