Care Plan Not Updated for New Wound and Catheter Care Orders
Penalty
Summary
The facility failed to update a resident's care plan to reflect new diagnoses and treatment interventions. Specifically, a resident admitted with multiple complex conditions, including Type II Diabetes Mellitus, chronic heart failure, hypertensive heart disease, a traumatic amputation, and benign prostatic hyperplasia, received new physician orders for wound care and foley catheter care. However, a review of the resident's care plan showed that it had not been revised to include these new interventions. During an interview, the DON confirmed that the care plan was not updated to address the wound care and catheter care needs, acknowledging that this did not meet expectations. The lack of updates to the care plan was identified through record review and staff interview, and no information about the new wound or catheter care interventions was present in the care plan at the time of review.