Failure to Update Care Plans for Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated to reflect the current needs and preferences of three residents. For one resident with major depressive disorder and PTSD, the care plan did not include her PTSD diagnosis or interventions to prevent re-traumatization, nor did it mention the use of a foot cradle that had been implemented months prior. Staff members, including CNAs and the MDS coordinator, were unaware of the resident's trauma history, triggers, or the specialized equipment in use, indicating a lack of communication and documentation regarding her psychosocial and physical care needs. Another resident's care plan did not reflect her preference to skip breakfast or her use of a hiking water bladder for fluid intake while in bed, despite staff being aware of these preferences and accommodations. The omission of these details from the care plan meant that her individualized dietary and hydration needs were not formally documented for all staff to follow. The intake team and MDS coordinator typically managed care plan updates, but these specific preferences and equipment were not included. A third resident's care plan listed a resolved surgical wound on the neck but failed to document current venous stasis wounds on both lower legs and the use of Unna boots for treatment. Nursing staff confirmed the presence of these wounds and the ongoing treatment, but the care plan was not updated to reflect the current skin integrity issues or interventions. The facility did not provide a care plan policy during the survey, and staff interviews revealed inconsistent practices regarding the inclusion of wound treatments and specialized equipment in care plans.