Deficiencies in Care Plan Updates and Safety Measures
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect changing care needs for several residents. Resident #28, who had severe cognitive loss and a history of falls, did not have an updated care plan addressing toileting needs despite multiple falls. Similarly, Resident #47, with severe dementia and a history of falls, had care plans that were not revised after several falls, indicating a lack of proactive measures to prevent future incidents. Resident #60's care plan did not specify the resident's code status preferences, despite the resident choosing to be a Full code. This lack of specificity in the care plan could lead to confusion regarding the resident's advance care planning. Additionally, residents #8, #14, and #19 were observed with bilateral half siderails in use, but their care plans did not address the use, consent, assessment, and monitoring of these siderails, which is a critical oversight in ensuring resident safety. The Director of Nursing was unaware of the siderails' presence, indicating a disconnect between policy and practice. The facility's policy requires comprehensive person-centered care plans, but the observed deficiencies highlight a failure to adhere to this policy, resulting in inadequate care planning and potential safety risks for the residents.