Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were accurate and updated for two residents. For one resident, the care plan did not reflect the resident's current needs as it was not updated to include the use of a mechanical lift for transfers, despite physician orders indicating its necessity. The resident's care plan also inaccurately documented the level of assistance required for personal hygiene and dressing, which did not match the resident's admission assessment data. The MDS coordinator acknowledged the discrepancies and confirmed that the care plan did not align with the resident's current needs and physician orders. Another resident, who was admitted with anxiety disorder and cognitive communication deficit, was identified as an elopement risk after attempting to leave the facility. Despite this, the resident's care plan did not include elopement precautions. The MDS coordinator and the facility administrator both recognized that the care plan should have been updated to reflect the resident's elopement risk once it was identified. The lack of updates to the care plans for both residents indicates a failure in maintaining accurate and current care plans, which is essential for ensuring appropriate care and safety.