Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to update and revise individualized, person-centered care plans to reflect the changing needs of four residents, as observed through direct care, interviews, and record reviews. For one resident with a Stage 4 pressure injury, staff did not document air mattress settings or provide clear instructions for adjusting the mattress, and wound care was performed without proper infection control, including cross-contamination during dressing changes. The care plan lacked specific interventions for the air mattress and did not reflect the current wound status, despite the wound progressing from Moisture Associated Skin Damage to a Stage 4 pressure ulcer. Another resident with a tracheostomy and multiple comorbidities was found to have three small pressure ulcers during observation, but the care plan had not been updated to document these open areas. The care plan continued to state that the resident's skin would remain intact, failing to reflect the actual skin condition. Similarly, a third resident dependent on dialysis and with multiple diagnoses reported significant pain, but the pain management care plan only included pharmacological interventions and omitted non-pharmacological approaches, despite facility policy requiring such interventions. The resident confirmed that staff did not implement non-pharmacological pain relief measures. A fourth resident with multiple pressure ulcers and cognitive impairment had a care plan that referenced the use of an air mattress and psychotropic medication monitoring but lacked individualized details such as specific air mattress settings and resident-specific information on behaviors or medication side effects. Staff interviews revealed uncertainty about where to find or how to document these individualized interventions, and the care plan did not provide clear guidance for staff. Across all cases, the care plans were not timely or adequately updated to reflect the residents' current conditions and needs as identified through assessments and observations.