Failure to Develop and Document Comprehensive Care Plans and Timely Update Interventions
Penalty
Summary
The facility failed to develop and document comprehensive care plans in accordance with regulatory requirements for several residents. For one resident with multiple complex diagnoses, including ulcerative colitis, malnutrition, and cognitive impairment, there was no evidence of an interdisciplinary meeting involving the resident or their representative to develop a comprehensive care plan during their stay. The care plan was created without the required care conference, and the resident was not scheduled for a care conference before discharge. Staff interviews confirmed that care conferences were not held within the required timeframe for new admissions, as the facility scheduled them only within three months of admission, regardless of the resident's length of stay. For two other residents with significant psychiatric and medical conditions, there was no documented proof in the medical records that care plan meetings with the required participants were held within the past year. One resident reported never being invited to a care conference, and the facility's social service designee confirmed the absence of documentation for care conferences in the medical records. In another case, care plan meetings were not held at the required quarterly intervals, and when meetings did occur, there was no evidence that all required interdisciplinary team members were present. Additionally, the facility failed to timely update fall interventions in the care plan for a resident with a history of falls and multiple neurological and nutritional diagnoses. Despite several falls and the implementation of new interventions such as bed adjustments, fall mats, and non-skid footwear, these changes were not promptly reflected in the resident's care plan. The Director of Nursing confirmed that the care plan had not been updated as required following each fall event. Facility policy required resident and representative participation in care planning and timely updates to care plans as conditions changed, but these expectations were not met in the reviewed cases.