Care Plans Not Updated to Reflect Residents' Clinical Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of three residents. For one resident, there was an order to cleanse and treat an anal fissure, but the comprehensive care plan did not address this condition. Additionally, this resident was noted to be constipated according to the Minimum Data Set, but no care plan was developed or implemented for constipation. The Director of Nursing Services acknowledged that both the anal fissure and constipation should have been included in the care plan but were not. Another resident was admitted with a peripherally inserted central catheter (PICC) and an order for intravenous antibiotics due to septic arthritis and spondylodiscitis, but the care plan did not address the type, location, number of lumens, or maintenance and monitoring instructions for the PICC. Similarly, a third resident had a PICC for IV infusions to treat muscle calcification, but the care plan lacked documentation regarding the PICC's type, location, number of lumens, and maintenance and monitoring instructions. In each case, the DON confirmed that these aspects should have been included in the residents' care plans.