Failure to Maintain Comprehensive and Updated Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive and up-to-date care plans were developed and implemented for three residents, resulting in deficiencies related to continuity of care. For one resident with a long-term indwelling urinary catheter, the care plan did not include Enhanced Barrier Protection (EBP) measures as recommended by CDC guidelines for residents at high risk of multidrug-resistant organism (MDRO) transmission. Observations confirmed the absence of PPE signage or equipment outside the resident's room, and staff interviews revealed reliance on care plans for guidance, yet the necessary infection control interventions were not documented or implemented. Another resident with diagnoses of alcoholic cirrhosis and alcohol dependence had multiple documented episodes of alcohol use within the facility, including possession and consumption of alcohol in their room. Despite repeated incidents and staff awareness, the care plan did not address the resident's substance use, associated risks, or interventions for monitoring and assessment. Staff interviews confirmed that care plans are used to inform monitoring practices, but the lack of documentation meant new or unfamiliar staff would not have clear guidance on managing the resident's ongoing alcohol use. A third resident with multiple chronic conditions, including diabetes, depression, and hypertension, as well as an active discharge plan, had a care plan that lacked essential information. The care plan did not address the resident's abilities with activities of daily living (ADLs), use of assistive devices, discharge planning, medication management, or the management of their medical and psychiatric diagnoses. Interviews with staff and the director of nursing confirmed that these omissions were inconsistent with facility policy and expectations for comprehensive care planning.