Failure to Update Care Plans and Conduct Required Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans (CPs) were updated and revised as needed to reflect person-centered care for several residents, and did not provide required care plan meetings for others. For four residents, care plans were not revised to reflect changes in condition, interventions, or individualized needs. For example, one resident with a brain injury and significant weight loss had a care plan that lacked clear parameters for safe weight loss and did not specify when weights should be taken, despite a documented 14.2-pound loss in one month. Another resident who was dependent on tube feeding had conflicting care plans regarding oral intake and tube feeding details, and the care plan did not address the resident's language barrier or specify the correct type and rate of tube feeding as reflected in the medication administration records. A third resident receiving antipsychotic medication for bipolar disorder with psychotic features had a care plan that did not include monitoring for hallucinations, which was a directive from the psychiatric practitioner, and incorrectly listed neurogenic bladder instead of obstructive uropathy as a diagnosis. Another resident who was independently mobile with a walker continued to have a care plan requiring two-person mechanical lift transfers, which was not updated to reflect the resident's current abilities, as confirmed by staff interviews and direct observation. Additionally, the facility failed to provide or document care plan meetings for four residents as required by policy. One resident reported never having a care plan meeting since admission, and staff confirmed there was no documentation of such a meeting. Another resident did not have a care conference until more than six months after admission, despite policy requiring one within 72 hours and quarterly thereafter. For another resident, there was no documentation of a care conference being offered or provided, and for one resident, only the family member attended the care conference without the resident or the full interdisciplinary team, with no documentation explaining the absence.