Failure to Revise and Update Care Plans and Conduct Timely Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected the care needs of three residents, and that care conferences occurred in a timely manner. For one resident with pulmonary fibrosis and chronic respiratory failure with hypoxia, there was no care plan addressing their respiratory conditions, despite the resident requiring oxygen therapy and having recent respiratory symptoms. Both a registered nurse and a care coordinator confirmed that a care plan for these conditions should have been in place upon admission. Another resident with multiple diagnoses, including heart, kidney, and liver disease, as well as diabetes and depression, reported being unaware of their medical plan of care and stated that staff had not discussed their medications, therapy, or treatments for some time. The social services director acknowledged that a scheduled care conference had been missed due to a glitch in the electronic health record system, and the director of nursing services confirmed that care conferences are typically organized by social services in coordination with nursing staff. A third resident, who was dependent on dialysis and had a fluid restriction order, had a care plan that did not reflect the most current provider order for fluid restriction. The care plan listed a 1000 ml per day restriction, while the provider's order had been updated to 1200 ml per day. Staff interviews confirmed that the care plan had not been revised to match the new order, and the director of nursing services stated that the care plan did not meet expectations.