Failure to Revise and Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise care plans for two residents as required. For one resident with a history of cancer, anxiety, depression, psychotic disorder, spinal stenosis, and dysphagia, the care plan did not accurately reflect the resident's current status regarding the use of a feeding tube at night and supervised oral intake. The care plan contained outdated interventions, such as indicating the resident was independent with eating and NPO, despite changes in the resident's condition and physician orders. Staff interviews confirmed that the care plan should match the resident's current needs and abilities, and the facility's policy required updates to the care plan upon a change in condition. For another resident with moderate cognitive deficits, serious mental illness, and a legal guardian, the care plan failed to include goals and interventions related to the resident's ongoing sexual relationship with another resident. Although the care plan noted the existence of a sexual relationship, it lacked specific interventions or goals to address this issue. The administrator acknowledged that such information should be included in the care plan. These deficiencies were identified through observations, staff interviews, clinical record review, and policy review.