Failure to Revise and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for four residents as required, resulting in care plans that did not accurately reflect the residents' current medical conditions, interventions, or measurable timeframes. For one resident with severe cognitive impairment and functional limitations, the care plan for the use of a half side rail did not specify the medical condition necessitating the side rail, lacked measurable timeframes, and did not include reassessment for safe use. The Director of Nursing (DON) acknowledged that the care plan was not updated to reflect the resident's current needs, despite being aware of the requirement. Another resident with dementia, diabetes, and significant weight loss had a care plan that was not revised to reflect current dietary orders or interventions following the weight loss. The care plan contained outdated and undated handwritten notes, lacked measurable timeframes, and did not align with the resident's current physician orders for diet. Similarly, a third resident with vascular dementia and a history of amputation had a care plan for the use of a half side rail that did not document the medical reason for the side rail, did not include timeframes, and omitted the need for reassessment, as confirmed by the Assistant Director of Nursing (ADON). A fourth resident with dementia, hypertension, and diabetes was observed multiple times using a Geri-chair with a tray table, which functioned as a physical restraint. The care plan for this resident did not include interventions for removing the tabletop or assessing the continued need for the restraint, nor did it provide measurable timeframes for goals. Observations showed the resident was frequently in the Geri-chair with the tray table attached, and staff interviews confirmed the resident was always up in the chair with the tabletop. The facility was unable to provide a care plan policy when requested.