Failure to Develop and Revise Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans were developed, reviewed, and revised in accordance with regulatory requirements for several residents. For one resident with a history of stroke and severe cognitive impairment, the care plan included an intervention for the use of heel protectors to address skin impairment and pressure injury risk. However, observations revealed that heel protectors were not in use while the resident was in bed, and there was no current physician's order for them. Staff interviews indicated a lack of awareness regarding the intervention, and the care plan was subsequently revised to remove the heel protectors without clear documentation of the clinical decision-making process. Another resident, admitted with dementia and other neurological diagnoses, had care plan documentation that did not reflect timely quarterly care plan conferences. The care plan history showed only two completed care plans despite the resident's ongoing stay, and the Social Service Director was unable to explain the lack of regular care plan reviews. This failure to conduct and document regular care plan conferences limited the facility's ability to assess, review, and revise care plans as needed. Additionally, a resident with multiple physical disabilities and incontinence did not have a care plan that addressed incontinence management or specific transfer assistance needs. Staff interviews confirmed the resident was incontinent and required frequent checks and changes, but this was not reflected in the care plan. Similarly, the care plan did not specify the resident's transfer needs, despite staff routinely using two-person transfers and gait belts. Facility policies required care plans to be updated with such information, but this was not done, resulting in incomplete care planning for the resident.