Failure to Update and Individualize Resident Care Plans
Penalty
Summary
Surveyors identified that the facility failed to ensure care plans were reviewed and revised to reflect the current care needs for seven of twelve sampled residents. Multiple observations, record reviews, and interviews revealed that care plans did not include essential information about residents' current conditions, interventions, and preferences. For example, one resident who spent significant time working on puzzles and was preparing for discharge had no documentation in his care plan regarding his activity interests or discharge plans. Another resident, who was on a therapy maintenance and positioning program requiring her feet to be elevated in a recliner, had no mention of this intervention in her care plan, and the director of nursing was unaware of the program's existence for this resident. Additional deficiencies were noted for residents with complex behavioral and medical needs. One resident with severe anxiety, pacing, and crying behaviors had no documentation in her care plan of non-pharmacological interventions or updates regarding the removal of bed rails, despite ongoing behavioral symptoms and changes in her care. Another resident self-administered topical medications as ordered by a physician, but this was not addressed in his care plan. Residents with mental health diagnoses, such as PTSD and major depressive disorder, also had care plans lacking interventions or strategies to address their specific behavioral health needs, including triggers and coping mechanisms. In one case, a resident's care plan did not reflect the use of a CPAP machine for obstructive sleep apnea, despite the resident's long-term use of the device. Interviews with staff, including the DON, LPNs, and social service designee, confirmed that care plan updates were primarily completed by the MDS nurse and that there was no formal audit process in place. Staff were often unaware of whether specific interventions or resident needs were included in the care plans. Facility policies required individualized, interdisciplinary care plans that addressed current needs and preferences, but these were not consistently followed, resulting in care plans that did not accurately reflect the residents' current care requirements.