Failure to Revise Care Plans to Reflect Current Resident Needs and Interventions
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions for five residents. For one resident with a history of surgical aftercare and schizoaffective disorder, the care plan contained conflicting dietary instructions and was not updated to reflect a physician's order for a full liquid diet, despite staff acknowledgment of the need for this intervention. Another resident with chronic kidney disease and mobility issues had a care plan indicating Enhanced Barrier Precautions (EBP), but EBP had been discontinued and this change was not reflected in the care plan or in the room signage and supplies. A third resident with spina bifida, anxiety, depression, and PTSD had a care plan that did not document her request for no male caregivers, a preference confirmed by staff as necessary due to her history. Additionally, a resident with heart and respiratory failure had a care plan that was not updated to include new oxygen parameter orders, as confirmed by the ADON. Another resident with brain compression and aphasia had a fall mat intervention in place at the bedside, but this was not documented in the care plan. Staff interviews and observations confirmed that these care plans were not revised in accordance with the facility's policy, which requires updates after each assessment and as resident needs change.