F0657

E

Failure to Revise Care Plans for New Orders, Resolved Conditions, and Noncompliance

Socorro, New Mexico Survey Completed on 12-16-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to revise and maintain accurate, up‑to‑date care plans for multiple residents after changes in medical orders, conditions, or behaviors. For one resident with chronic respiratory failure and chronic bronchitis, physician orders were in place for oxygen via nasal cannula and for weekly changes of oxygen tubing and water on the concentrator, yet the care plan dated after these orders did not include any interventions related to oxygen use or weekly nasal cannula changes. During interview, the Regional Clinical Nurse (RCN) confirmed that the care plan lacked these oxygen-related orders and that staff were expected to document oxygen and nasal cannula orders in the care plan.

Another resident with dementia, major depressive disorder, anxiety, and a history of other mental and behavioral disorders had physician orders for quetiapine fumarate for agitation and anxiety and Lasix for edema. The care plan did not document that the resident was receiving an antipsychotic or a diuretic, nor did it include any monitoring interventions for these medications. The RCN confirmed that the care plan had not been revised to reflect the use of quetiapine fumarate or Lasix and that staff were expected to revise care plans when residents start antipsychotic or diuretic medications. A separate resident with lack of coordination, gait abnormalities, and muscle weakness had an order for an anti‑rollback device on the wheelchair and a prior care plan entry for a painful tooth infection with a planned dental visit. The care plan documented only that the resident would be evaluated for an anti‑rollback lock, without documenting that the device had been installed or listing interventions for its use, and it continued to list an active tooth infection even after the infection had resolved and the resident had seen a dentist. The MDS Coordinator confirmed the infection was no longer current and stated the care plan should have been updated when it resolved, and the DON stated care plans should reflect current interventions and be updated when a diagnosis is resolved.

For another resident with dysphagia on a prescribed pureed, thin‑liquid diet, observation and interview showed the resident disliked the pureed diet, preferred to choose foods such as cottage cheese, crackers, and snack cakes, and had chocolate snack cakes at the bedside. The dietitian confirmed that chocolate snack cakes did not match the ordered diet consistency and that the resident tended to pick and choose foods, favoring meat and desserts. The care plan, however, did not document that the resident was noncompliant with the ordered diet. The RCN confirmed that the care plan lacked a revision to address this noncompliance and that her expectation was for a specific plan addressing the resident’s noncompliance.

A further resident with psychotic disorder with delusions, major depressive disorder, and anxiety disorder had physician orders for quetiapine fumarate three times daily for psychosis and sertraline once daily for depression. The care plan, last revised before these orders, did not document the antipsychotic or antidepressant medications or any monitoring interventions for them. The RCN confirmed that the care plan had not been revised to include these medications or monitoring for side effects and reiterated that staff were expected to revise care plans when residents start antipsychotic or antidepressant medications. Across these cases, record review, observation, and staff interviews showed that care plans were not revised to reflect current physician orders, resolved conditions, new medications, or resident noncompliance, resulting in care plans that did not contain the most current resident information and interventions.