Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive and updated care plans were developed and maintained for several residents, as required. Specifically, no discharge care plans were developed or updated for four residents, despite ongoing discharge planning activities and changes in their discharge status. For example, one resident with dementia and fluctuating decision-making capacity had a care plan that was not updated to reflect changes in discharge arrangements, even after multiple placement attempts and behavioral concerns. Another resident, admitted with congestive heart failure and respiratory failure, had no documented discharge care plan despite being informed of a short-term stay and receiving resources for post-discharge needs. Additional residents, including one with osteomyelitis and another with encephalopathy and kidney failure, also lacked documented discharge care plans, even as discharge planning and placement activities were underway. Interviews with staff confirmed that care plans should have been initiated and updated as discharge processes progressed, but this was not done. The facility also failed to develop a care plan for the use of an indwelling catheter for a resident with multiple urinary diagnoses, including benign prostatic hyperplasia and urinary retention. Despite physician orders for daily catheter care and specific instructions for catheter management, there was no care plan addressing the resident's catheter use. Observations confirmed the presence of cloudy urine with sediment, and both nursing staff and the DON acknowledged the absence of a care plan for this intervention. Additionally, the facility did not develop a care plan to address a change in condition for a resident who developed a urinary tract infection (UTI). The resident reported symptoms, and diagnostic testing confirmed a UTI caused by E. coli, but there was no documented care plan to address this new condition. The DON confirmed that a care plan should have been developed in response to the change in condition. Facility policies and job descriptions reviewed indicated that care plans should be developed and updated by the interdisciplinary team to reflect residents' needs and changes in condition, but this was not consistently done.