Failure to Timely Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to make timely and appropriate revisions to the comprehensive person-centered care plans for four out of six sampled residents. For one resident admitted for pneumonia due to Coronavirus, the care plan was not updated to reflect the family's request for daily clothing changes and for the resident to be up for all meals, nor did it include the resident's need for 1:1 feeding assistance and one-person assist for activities of daily living and transfers, despite these needs being documented in progress notes and addressed verbally with staff. Another resident with metabolic encephalopathy, hypoxic respiratory failure, and other chronic conditions had a care plan that did not accurately reflect the physician's emergency oxygen order. Similarly, a third resident with a history of respiratory failure and multiple falls had a care plan that was not revised after three falls to include the use of floor mats or other new interventions, even though these were implemented and documented elsewhere in the record. A fourth resident with Parkinson's disease, severe dysphagia, and a history of aspiration pneumonia had a care plan that did not reflect current physician orders for oxygen administration, the presence of a Stage 3 pressure injury, or the use of preventive heel boots. Additionally, the care plan did not accurately reflect the resident's current dietary orders and feeding needs, as it was not updated after changes in the resident's nutritional status and interventions. The Director of Nursing confirmed that the care plans had not been revised to reflect current orders and interventions.