Failure to Update Care Plans to Reflect Residents' Current Needs
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents to reflect their current needs as required by policy. For one resident with diagnoses including Alzheimer's dementia, diabetes, and weakness, the care plan did not reflect the resident's discharge from hospice services, despite a physician order indicating the change in status. For another resident with dementia, bipolar disorder, and a history of repeated falls, the care plan did not document the resident's bed being placed against the wall per the request of the resident and family for comfort, as observed during a room inspection. These deficiencies were confirmed through clinical record review, staff interviews, and direct observation. The facility's policy requires that care plans be developed and updated to reflect individualized needs and changes in resident status, but in these cases, the care plans were not revised to account for significant changes in the residents' conditions and preferences.