Care Plan Deficiencies and Lack of Documentation
Penalty
Summary
The facility failed to ensure that care plans were accurately developed, updated, and individualized for several residents, as required. For multiple residents, care plans did not reflect current clinical needs or services, such as hospice care, transfer assistance requirements, and behavioral interventions for conditions like PTSD. In one instance, a resident receiving hospice care was not identified as such in the care plan, and another resident's care plan did not match the documented need for assistance with transfers, despite staff providing substantial help during observed care. Additionally, care plans for residents with cognitive impairments lacked updates on their interests, preferences, and activity options, and in some cases, contained inaccurate cognitive assessment scores. The facility also failed to document care conferences as required, with several residents not having records of care conferences during the survey year. One resident reported not being invited to care conferences, and the Assistant Director of Nursing confirmed the absence of documentation due to personnel changes. Facility policies required that activity interests be identified in the care plan and reviewed quarterly, and that care conferences occur quarterly, but these requirements were not consistently met. These deficiencies were identified through observation, clinical record review, policy review, and staff interviews.