Failure to Update and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed, revised, and implemented according to the resident's changing needs and physician orders. The resident, an elderly female with diagnoses including dementia, Alzheimer's disease, dysphagia, peripheral vascular disease, and urinary incontinence, had multiple care needs that were not accurately reflected or updated in her care plan. For example, her care plan did not address the need for a geri chair with direct supervision as ordered, nor did it reflect the restriction against using a broda chair. Additionally, the care plan failed to include the administration of pain medication one hour prior to wound dressing changes, despite a physician's order for this intervention. The resident experienced new onset seizures, but her care plan did not include this diagnosis or interventions for seizure precautions and injury prevention. There was also a lack of updated interventions following the deterioration of her unstageable pressure injury, such as specific positioning or offloading measures. The care plan did not reflect the need for frequent repositioning as documented in provider notes, nor did it address the significant weight loss the resident experienced over a three-month period. Dietary orders for pureed food and nectar thick liquids by teaspoon were not fully incorporated into the care plan, and the use of inappropriate feeding utensils, such as straws, was observed during meal assistance. Furthermore, the care plan lacked individualized details regarding the resident's food preferences, dislikes, and effective non-pharmacological pain interventions. Staff interviews and observations confirmed that the care plan was not consistently referenced or followed, leading to discrepancies between the resident's documented needs and the care provided. These omissions and failures to update the care plan resulted in incomplete and potentially inappropriate care measures for the resident.