Failure to Maintain Comprehensive and Updated Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and maintain comprehensive care plans for multiple residents with significant clinical needs. For one resident with obstructive and reflux uropathy, the care plan for an indwelling urinary catheter was created upon readmission but was resolved prematurely without proper reassessment or verification of the catheter's presence. Despite documentation and clinical notes indicating the continued use of the catheter, the care plan was not updated until after a subsequent hospitalization, indicating a lapse in ongoing assessment and care planning. Another resident with end stage renal disease and dependence on hemodialysis experienced a change in dialysis schedule as ordered by the physician. However, the care plan was not updated to reflect the new dialysis days, as the change was not communicated effectively during clinical meetings and was not incorporated into the care plan by the responsible staff. This resulted in the care plan containing outdated information regarding the resident's dialysis schedule. A third resident with oropharyngeal dysphagia and severe cognitive impairment had a change in dietary status to nothing by mouth (NPO) as per physician order. The care plan, however, continued to indicate that the resident received a meal tray and was not updated to reflect the NPO status. Staff interviews confirmed that changes in care were communicated during clinical meetings, but the care plan was not revised accordingly, leading to discrepancies between the resident's current orders and the documented care plan.