Failure to Revise and Update Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise and update care plans for three residents in accordance with its own policy and federal regulations. Specifically, there was no evidence of revised care plans for one resident regarding denture care, another resident regarding diabetes mellitus, and a third resident regarding midline dressing care. Record review showed that these residents had significant medical histories, including Alzheimer's disease, type 2 diabetes mellitus, and sepsis. The facility's policy requires that care plans be created and updated to reflect each resident's needs, including physician's orders, diagnoses, and rehabilitative potential, but this was not done for the identified care areas. Interviews with staff, including LPNs, the MDS Coordinator, the DON, and the ADON, confirmed that care plans were not updated as required. Staff reported confusion or lack of clarity regarding responsibility for updating care plans, with some stating that only baseline care plans were completed at admission and not revised thereafter. The MDS Coordinator and nursing leadership acknowledged the lack of updated care plans and recognized that this failure could result in residents not receiving appropriate care for their conditions.