Failure to Update Care Plans to Reflect Current Resident Needs
Penalty
Summary
The facility failed to update and revise care plans to reflect the current care needs and conditions of two residents. For one resident with a history of neurogenic bladder, multiple sclerosis, and anxiety disorder, the care plan continued to reference bilateral ankle casts, despite observations and staff interviews confirming that the casts had been removed almost a year prior. The care plan had not been updated to remove this outdated intervention, and both the LPN and DON acknowledged that the care plan should not reference casts if they were no longer present. For another resident with arthritis, multiple sclerosis, malnutrition, and who was receiving hospice services, the care plan did not include a focus area or interventions related to hospice care. Additionally, the care plan inaccurately stated that the resident was able to feed himself, despite the MDS indicating the resident required substantial to maximal assistance with eating. The facility's policy requires care plans to be revised as resident conditions change, but this was not followed in these cases.