Failure to Update and Implement Care Plans and Conduct Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans were updated and implemented in accordance with regulatory requirements for multiple residents. For one resident with a history of unspecified mild dementia with psychotic disturbance, a care plan indicated the presence of a venous access device and administration of IV antibiotics for a urinary tract infection due to ESBL. However, after the completion of the antibiotic course and removal of the IV access, the care plan was not updated to reflect these changes. Additionally, both quarterly and annual MDS assessments lacked documentation of antibiotic administration or IV access during the relevant periods, despite clear evidence from progress notes and resident interviews that these interventions had occurred and subsequently ended. Another resident, who experienced frequent pain and was prescribed as-needed opioid pain medication, did not have a care plan implemented for pain management or opioid use, despite regular administration of the medication and frequent complaints of pain interfering with activities of daily living. The DON and MDS coordinator were unaware of the absence of a pain management care plan, even though the resident had been receiving pain medication consistently since admission. The facility also failed to conduct and document quarterly care plan meetings for a resident with severe cognitive impairment. The resident's daughter reported never being invited to a care plan meeting, and the record lacked documentation of such meetings prior to a specific date. The Social Service Director acknowledged not inviting the family due to missing contact information and was unaware of previous documentation practices. The Administrator confirmed the absence of documentation verifying that care plan meetings were held as required.