Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy and regulatory standards. For one resident with diabetes and a history of skin cancer, the care plan did not include information about a chronic skin condition or a sore on the top of the head, despite multiple progress notes and interviews indicating the presence of a recurring, inflamed mole. Staff and the resident reported the area had been treated previously and continued to cause discomfort, but this was not reflected in the care plan. Documentation showed that staff were aware of the issue, applied treatments as needed, and eventually scheduled a dermatology appointment, but the care plan remained incomplete regarding this ongoing skin concern. For another resident with severe cognitive impairment and multiple comorbidities, including heart failure, chronic kidney disease, and dementia, the care plan was not updated in a timely manner to reflect the initiation of hospice care. There were discrepancies in physician order dates, hospice admission documentation, and the timing of care plan updates. Interviews with staff revealed that care plans and MDS assessments were not consistently accurate or current, and that the process for updating care plans was not well managed, with various staff members making entries without a clear system. The facility's own policy requires that comprehensive, person-centered care plans be developed and updated to address all identified needs and services, with measurable objectives and timeframes. However, the care plans for these two residents did not meet these requirements, as they lacked critical information about current conditions and services, and were not revised in accordance with changes in the residents' status or care needs.