Failure to Revise Care Plan After Resident Eye Condition Change
Penalty
Summary
The facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after a documented change in condition for one resident. The resident was an older male with an initial admission in early April 2023 and a recent readmission, with diagnoses including dry eye syndrome, cerebral infarction, dementia, congestive heart failure, dizziness and giddiness, and chronic cough. An MDS assessment showed a BIMS score of 13 and indicated the resident could see fine detail such as regular print. A change in condition progress note dated 01/27/2026 documented that the resident developed redness to the right eye with a small amount of drainage, and the physician ordered Azithromycin 1% ophthalmic solution, one drop to the right eye twice daily for five days. The Medication Administration Record reflected this new order dated 01/27/2026. Despite this documented change in condition and new treatment order, review of the resident’s care plan showed no indication of a change in condition regarding the eye. Interviews with the DON, Administrator, MDS Specialist (LVN), and ADON confirmed that the facility’s expectation and policy were that care plans be updated immediately or within 24 hours after a status change, typically following SBAR completion and IDT discussion, and that such updates are then communicated to staff via the Kardex. The DON acknowledged that for this resident the care plan was not updated timely and accepted accountability. Staff interviews consistently identified that the care plan should have been revised after the change in condition was identified and the new order was received, but this did not occur for the resident’s right eye redness and drainage.
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