Failure to Timely Update Resident Care Plans to Reflect Current Conditions and Interventions
Penalty
Summary
The facility failed to update and revise resident care plans in a timely manner to reflect current conditions and interventions for five residents. For one resident with diabetes and end stage renal disease, the care plan continued to list a discontinued topical numbing cream, despite documentation in the progress notes and treatment administration record that the intervention had been stopped due to patient complaints. The MDS Coordinator acknowledged that the care plan did not reflect the current medicated cream in use. Another resident with multiple diagnoses, including diabetes, heart failure, and a colostomy, had a care plan that listed negative pressure wound therapy (NPWT) and a weight goal that did not match the resident's current weight trend. The NPWT had been discontinued, and the registered dietitian acknowledged that the nutrition care plan had not been updated to reflect the resident's actual weight. Similarly, a resident with severe cognitive impairment and multiple comorbidities had a care plan that did not include a physician-ordered protein supplement for wound healing, nor did it reflect the resident's current weight trend, despite documentation in the electronic health record. Additional deficiencies included a resident with a stage 3 pressure ulcer whose care plan did not reflect her refusal to use a chair cushion or alternative interventions, and another resident whose care plan did not accurately reflect her current code status, transfer needs, or hospice services. Staff interviews confirmed that care plans were not consistently updated to reflect changes in health status, interventions, or resident preferences, despite facility policy requiring ongoing assessment and timely revision of care plans.