Failure to Update Care Plan After Change in Resident Status
Penalty
Summary
The facility failed to revise the care plan for a resident to accurately reflect the resident's current status and preferences. The resident, who was alert and oriented, had a history of high blood pressure, muscle weakness, and malnutrition. Documentation showed that the resident regularly visited his wife in the attached personal care unit, Vista, and was found there by staff after being reported missing from the skilled facility. Following this incident, a physician's order was obtained allowing the resident to visit his wife if escorted by staff, and both staff and the resident were educated on this requirement. Despite these developments, the resident's care plan was not updated to include his preference for visiting his wife or the new requirement for staff escort during these visits. This omission was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the care plan had not been revised as required by facility policy and regulatory standards.