Care Plans Not Updated to Reflect Residents' Current Status
Penalty
Summary
The facility failed to ensure that comprehensive care plans were revised and accurately reflected the current status of two residents. For one resident with a history of constipation, fecal impaction, anemia, contractures, and cerebellar stroke, the care plan listed a pressure injury as a problem area, despite no evidence of a pressure injury in the medical record. Additionally, the care plan for pain management did not include individualized non-pharmacological interventions, and this omission was confirmed by the Regional MDS Coordinator. For another resident with dysphagia, diabetes mellitus, metabolic encephalopathy, and who was edentulous, the care plan only addressed the potential for mouth pain related to the use of top dentures. The care plan was not updated to reflect the loss of the lower denture and the ongoing process of obtaining a replacement, despite documentation in dental consults and resident interviews indicating the resident had been waiting for new lower dentures for approximately six months. The Regional Nurse confirmed that the care plan had not been revised to include these developments.