Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect residents' current medical needs and preferences, as required by regulation. For one resident with multiple complex diagnoses, including morbid obesity, chronic kidney disease, and dependence on dialysis, the care plan for dialysis was not individualized and did not specify the presence of a fistula used for hemodialysis access. This omission was confirmed by both the resident and a registered nurse, who acknowledged that the care plan lacked details about the specific type of dialysis access and the services required. Another resident, with a history of metabolic encephalopathy, diabetes, and rheumatoid arthritis, had care plans that were not revised to reflect significant changes in condition or preferences over an extended period. Despite a significant change assessment indicating moderate cognitive impairment, increased behavioral symptoms, and new medical interventions such as continuous tube feeding, the care plan was not updated to address these changes. Observations and staff interviews revealed ongoing refusals of care, changes in activity participation, and the importance of religious activities, none of which were reflected in the care plan until after the surveyor's inquiry. The deficiency was identified through record review, observation, and staff interviews, which demonstrated that the interdisciplinary team did not consistently review and revise care plans after assessments or significant changes in residents' conditions. The lack of timely and individualized updates to care plans affected the delivery of person-centered care for at least two residents reviewed during the survey.
Plan Of Correction
The Facility will continue to implement and revise care plans to meet the needs of each resident. Resident #26 and #133 continue to reside at the facility. Resident #26 Care plan for dialysis was revised by the MDS nurse on 3/26/2025 to ensure proper care for dialysis treatments. Resident #133 was reassessed by the Activities Director on 3/26/2025 and revised activities care plan on 3/26/2025. An initial audit was conducted by the MDS Nurse to ensure accuracy of current activity care plans for residents who are bed bound and did not participate in many activities. 9 residents were identified and reviewed. No negative findings were noted. Resident #26 is the facility's only dialysis patient at this time. No initial audit was needed to be completed at this time. The Interdisciplinary team, who are responsible for creating a comprehensive care plan, and revising care plans were reeducated by the Regional Clinical Manager on 4/14/25, to ensure the care plans meet the current needs of the resident. Weekly for 2 weeks, or as directed by the QA committee, the MDS nurse will audit care plans for residents on dialysis and 5 random residents for activities, ensuring care plans are meeting the needs of the residents. Negative findings will be reported to the QA committee. Negative findings will be corrected by updating the care plans and reeducating staff. The Administrator will ensure weekly completion of audits and the DON is responsible for the ongoing compliance.