Care Plans Not Updated to Reflect Resident Needs
Penalty
Summary
The facility failed to ensure that resident care plans were updated and accurate to reflect the current needs of three residents. For one resident with a history of suicide attempts, the care plan did not include information about recent hospitalizations for suicide ideation and self-harming behaviors, despite documented incidents where the resident attempted to harm themselves and required emergency intervention and hospitalization. The care plan remained unchanged after these significant events, and staff interviews confirmed that these incidents should have been reflected in the care plan. Another resident, who was cognitively intact and diagnosed with end stage renal disease, received regular dialysis treatments as ordered by a physician. However, the resident's care plan did not address dialysis care, monitoring of the access site, or emergency procedures related to dialysis. Staff responsible for care plan updates acknowledged that dialysis should have been included as a focus area but was omitted due to oversight. A third resident, with moderate cognitive impairment and multiple diagnoses including schizophrenia and COPD, had no documentation in the care plan regarding discharge planning, despite the need for such planning. Staff interviews confirmed that care plans are expected to be updated quarterly and with significant changes, and that information regarding dialysis, discharge planning, and suicide ideation should have been included for these residents. The care plans in use at the time of the survey did not accurately reflect these residents' current needs.