Failure to Update Care Plans After Resolution of Acute Conditions
Penalty
Summary
The facility failed to review and revise resident care plans to reflect changes in condition and resolution of acute issues, as required by its policy and regulatory standards. The facility’s policy "Care Plan-Comprehensive" stated that assessments are ongoing and care plans are revised as information about the resident and the resident's condition change. For one resident with hypertension and chronic diastolic congestive heart failure who was treated for influenza from January 30, 2026, through February 6, 2026, the care plan contained an active focus for influenza dated January 30, 2026, that was not revised after the influenza resolved in early February 2026. The DON confirmed that the influenza had resolved and that the care plan should have been revised at that time. Another resident with vascular dementia and hearing loss was treated for a UTI from February 1–4, 2026, yet the care plan still showed an active UTI focus dated February 1, 2026, and had not been revised when the infection resolved. A third resident with Parkinson’s disease with dyskinesia and urinary retention had a UTI on November 1, 2025, that was resolved with treatment, but review of the care plan on February 4, 2026, showed the UTI remained listed as an active problem. During interviews, the NHA acknowledged that care plans should be revised when conditions such as UTIs resolve and agreed that care plans should reflect the resident’s current status.
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