Failure to Update Care Plan for Resident's Preferred Name and Skin Protection Measures
Penalty
Summary
A deficiency occurred when the facility failed to update and revise the care plan for a resident in accordance with the resident's current care needs. The resident, who had diagnoses including dementia, adult failure to thrive, and was receiving palliative care, had a severely impaired cognitive status as indicated by a BIMS score of 3 out of 15. Staff interviews revealed that the resident was sometimes called by a shortened version of their name or "grandma" to help calm behavioral episodes. However, a family member objected to the use of "grandma," and after discussion with the resident's POAHC, approval was given for staff to use the term if it was helpful. Despite this, the care plan was not updated to reflect the resident's preferred names. Additionally, the resident sustained an injury of unknown origin, and an investigation determined that the resident, known to be combative, had hit their arms on the bed. In response, geri-sleeves were implemented to protect the resident's skin, in collaboration with hospice staff. However, the care plan was not revised to include the use of geri-sleeves for skin protection. Both the ADON and DON confirmed that the care plan had not been updated to reflect these changes, despite the interventions being in place.