Failure to Revise Care Plans and Conduct Required Care Conferences
Penalty
Summary
The facility failed to ensure timely and accurate revisions to care plans and did not consistently conduct required care plan conferences for three residents. For one resident, after a significant change in condition and the identification of a new Stage II pressure ulcer on the coccyx following readmission, the care plan was not updated to include specific interventions or treatments for the new wound. Although the resident had existing skin care interventions, the care plan did not reflect the new care needs associated with the coccyx ulcer, as confirmed by the Assistant Director of Nursing (ADON). Another resident's care plan was not updated in a timely manner after the discontinuation of an indwelling urinary catheter. The resident's catheter was removed, and there were no active orders for its use for several months, yet the care plan continued to list catheter-related interventions until it was finally updated over four months later. Both the resident and the ADON confirmed the catheter had been discontinued well before the care plan was revised, and the administrator acknowledged the importance of care plans accurately reflecting current needs. Additionally, a third resident, who was cognitively intact and able to express their needs, was not invited to a care conference as required. Documentation showed only one care conference had been held several months prior, with no evidence of subsequent conferences or invitations. Staff interviews confirmed that care conferences should have been offered quarterly and that the resident should have been invited to participate.