Failure to Review and Revise Care Plans for Medication Changes, Fall Interventions, and Discharge Goals
Penalty
Summary
The deficiency involves the facility’s failure to review and revise comprehensive care plans in response to changes in residents’ conditions and needs for three of 32 residents. Facility policy required an interdisciplinary plan of care to be established and updated as indicated for every resident. For one resident with dementia and atrial flutter, the care plan continued to list focuses of psychotropic drug use and cardiovascular anticoagulant therapy that began in July 2025, even though the antipsychotic medication had been discontinued on January 8, 2026, and the anticoagulant medication had been discontinued on December 31, 2025. The DON confirmed that the care plan should have been revised when these medication changes occurred. Another resident with repeated falls and muscle weakness was observed lying in bed with fall mats on both sides of the bed, but the care plan, initiated in January 2024 for a history of falls, did not include the use of bilateral fall mats as an intervention. The DON stated that the care plan should have included this intervention. A third resident with peripheral vascular disease and spinal stenosis was observed lying in bed and repeatedly stating that she was waiting for a family member to take her home. Her care plan did not indicate whether her goal was to remain for LTC or be discharged to another level of care, despite care conference notes documenting that she wanted to go home alone, had been educated that her physician felt this was unsafe, and had declined assisted living. The DON acknowledged that this resident’s care plan should have reflected her choice for discharge or LTC at the facility.
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