Failure to Develop, Review, and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans within the required timeframe and did not ensure that care plans were reviewed and revised to reflect residents' current conditions. For one new admission, the interdisciplinary care plan meeting was not held, and the comprehensive care plan was not completed within 21 days as required by facility policy. The baseline care plan did not address all areas triggered by the admission MDS assessment, such as activities of daily living, rehabilitation potential, urinary incontinence, falls, dehydration, and pressure ulcers. The responsible RN acknowledged the care plan was overdue and incomplete, and could not provide a reason for the delay. Another resident's care plan was not updated to reflect changes in their activities of daily living (ADL) status, specifically regarding transfer and mobility needs. Despite physician orders and therapy notes indicating the need for a Hoyer lift with two-person assist, the care plan inaccurately described the resident as transferring and ambulating independently. The care plan was only updated after a fall occurred, and staff interviews confirmed that the care plan did not accurately reflect the resident's status prior to the incident. For a resident with pressure injuries, the care plan was not reviewed or revised when new skin issues developed, including a sacral pressure ulcer and a left heel wound. Documentation showed that the care plan did not reflect the resident's current skin status until after surveyor inquiry, despite multiple nursing notes and wound care interventions. Staff interviews confirmed that care plans should be updated following significant changes, but this was not done in a timely manner for the resident who developed new wounds.