Failure to Revise Care Plans After Changes in Treatment and Condition
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans for multiple residents after changes in condition, treatments, and interventions. For one resident with a history of seizures, falls, and sleep apnea, physician orders documented a regular pureed diet with thin liquids and oxygen at 2 L/min via nasal cannula with approval to wean off. Progress notes showed multiple falls on 11/14/25, 11/20/25, 12/04/25, and 02/04/26. Observation of the resident’s room revealed a camera positioned above the bed to monitor seizure activity and no oxygen concentrator present, and the resident was not wearing oxygen. However, the care plan last revised on 01/23/26 did not include any goals, instructions, or indications for the use of the camera, did not include interventions for the falls that occurred after 11/05/25, listed an incorrect diet texture of regular mechanical soft instead of puree, and continued to list oxygen therapy as continuous for sleep apnea. The DON confirmed that the camera use should be in the care plan but was not, that fall interventions had not been updated for the subsequent falls, that the diet texture in the care plan was incorrect, and that the care plan had not been revised to remove continuous oxygen. For another resident admitted with insomnia, depression, bipolar disorder, generalized anxiety disorder, and type 2 DM with unspecified complications, the physician record showed an order for Insulin Glargine 15 units subcutaneously daily that had been discontinued on 10/21/25. Despite this discontinuation, the resident’s care plan, last revised on 05/22/25, still contained an intervention to inject Insulin Glargine. This demonstrates that the care plan was not revised to reflect the discontinued insulin therapy. Across these residents, the survey findings show that the facility did not ensure care plans were updated to reflect current orders, treatments, and monitoring devices as required.
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