Failure to Individualize and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to timely review and revise person-centered comprehensive care plans for three residents, resulting in care plans that were not individualized or updated to reflect the residents' current needs. For one resident with chronic pain, the care plan did not include personalized non-pharmacological interventions to be attempted before administering pain medication. Both a licensed nurse and a certified nursing assistant confirmed that these interventions were missing from the care plan and the Kardex, despite the importance of such measures in potentially reducing the need for medication and its associated side effects. Another resident, admitted under hospice care with multiple diagnoses including atrial fibrillation and a pressure ulcer, had care plans for activities of daily living (ADLs), pressure ulcer management, and hospice services that were not personalized. The care plans did not specify the level of assistance required for ADLs, did not address risk factors or interventions for skin breakdown, and lacked details about hospice agency contacts, visit schedules, and specific tasks. Staff confirmed that this information was not available in the resident's Kardex, making it difficult for them to provide appropriate care. A third resident, who was an active smoker, had a care plan that did not include required interventions such as supervision and the use of a smoking apron during smoking sessions, as indicated by the resident's smoking safety screen. The activity director, assistant activity director, and MDS nurse all confirmed that these interventions were missing from the care plan, which could result in staff being unaware of necessary safety measures. The facility's policy requires care plans to be individualized and accessible to all caregivers, but this was not followed in these cases.