Failure to Update Care Plans for Resident Allergies and Preferences
Penalty
Summary
The facility failed to ensure that care plans were revised to accurately reflect changes in residents' needs and conditions. For one resident with Alzheimer's disease, atrial fibrillation, and major depressive disorder, the care plan was not updated after the resident's daughter requested a change in the resident's morning routine to allow the resident to stay in bed longer. Despite documentation of this request and a conversation with the administrator, the care plan continued to state that the resident was to get up early in the morning for safety, and no revision was made to address the family's concern. In another case, a resident with multiple diagnoses including type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia had allergies to several medications. The care plan failed to include two of the resident's known allergies, specifically to metformin and Ativan, even though these were documented in the allergy alert profile. The MDS Coordinator confirmed that all allergies should be reviewed quarterly and acknowledged that the care plan had not been updated to reflect these additional allergies. These deficiencies were identified through interviews and record reviews, and were not in accordance with the facility's policy requiring regular review and updating of care plans.