Failure to Update Care Plans and Involve Residents in Care Plan Conferences
Penalty
Summary
The facility failed to provide evidence of conducting resident care plan conference meetings or inviting residents and/or their representatives to such meetings, as well as failed to revise comprehensive care plans to reflect current care needs for two residents. For one resident with a history of a broken left hip, spinal stenosis with disc degeneration, and difficulty walking, the clinical record showed a physician's order for no weight bearing on the left leg. However, the care plan was not updated to reflect this non-weight bearing status, and the Director of Nursing confirmed this omission during an interview. For another resident with diagnoses including chronic obstructive pulmonary disease, anxiety, and hyperlipidemia, the clinical record lacked evidence that the resident or their representative had been invited to or attended a care plan conference meeting following the most recent assessment. The resident confirmed not being invited or attending such a meeting, and the Social Service Manager also confirmed the absence of documentation regarding care plan conference invitations or attendance. These findings were in violation of facility policy and state regulations regarding care planning and resident involvement.