Failure to Update and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in care plans that did not reflect current medical orders or the residents' actual care needs. For one resident, the care plan was not updated to reflect the removal of a PICC line and the discontinuation of wound care to the right femur and hip. Despite the discontinuation of these treatments, the care plan continued to list interventions related to the PICC line and surgical wounds, which created confusion among nursing staff regarding the resident's current care requirements. Interviews with nursing staff revealed that they relied on both care plans and medical orders, and discrepancies between the two could lead to uncertainty about the care to be provided. For another resident, the care plan was not updated to reflect a change in dietary orders from a pureed to a mechanical soft diet, as recommended by the speech therapist and documented in the medical record. The care plan continued to list interventions for a pureed diet, even though the resident was receiving and consuming a mechanical soft diet with thin liquids. Staff interviews confirmed that the resident's diet had been advanced, but the care plan did not match the current orders or the diet being provided. This discrepancy was acknowledged by the MDS nurse and other facility leadership, who indicated that care plans should be updated to match current orders to ensure appropriate care. The facility had recently transitioned to a new electronic medical record (EMR) system, and staff interviews indicated that care plans were expected to be updated in the new system. However, the process for updating care plans was not consistently followed, and responsibilities for updating care plans were shared among the MDS nurse, DON, ADON, and treatment nurse. The lack of timely updates to care plans resulted in documentation that did not accurately reflect the residents' current needs or the care being provided, as confirmed by multiple staff members and observations during the survey.