Failure to Update Care Plan with Resident's Caregiver Preference
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plan for one resident following the identification of a specific care preference. The resident, who was admitted with multiple diagnoses including spinal stenosis, cardiomyopathy, chronic respiratory failure, diabetes, and depression, was assessed as cognitively intact. During an interview, the resident expressed a preference for female caregivers to provide personal care, a preference that had been honored in practice by the facility. However, a review of the resident's care plan, last revised on 3/28/25, showed that while assistance with activities of daily living was documented, there was no mention of the resident's preference for female caregivers. Interviews with facility staff, including the LPN unit manager and the RN MDS coordinator, confirmed that this preference should have been included in the care plan but was not. The omission was acknowledged by staff during the survey, and no additional information was provided by facility leadership before the survey concluded.