Failure to Revise Care Plans for Resident-Centered Functional Abilities
Penalty
Summary
The facility failed to revise and update the care plans for two residents to include individualized, resident-centered functional abilities and specific directions for staff regarding activities of daily living (ADLs). For one resident with chronic respiratory failure, congestive heart failure, obstructive sleep apnea, anxiety, major depressive disorder, and diabetes mellitus, the care plan did not provide instructions for staff on essential ADL support such as toileting hygiene, transfers, bed mobility, bathing, oral hygiene, dressing, and eating. This resident required substantial to maximal assistance with these activities, as documented in the Minimum Data Set (MDS), and had multiple hospitalizations for decreased oxygen levels during the review period. Observations showed the resident needed repositioning for safe meal intake, and staff interviews confirmed that care plan directions were missing due to a mishap in the care planning process. Another resident with neuromuscular bladder dysfunction, hypertension, paraplegia, major depressive disorder, traumatic brain injury, anxiety, morbid obesity, a stage four pressure ulcer, and dependence on a wheelchair also had a care plan lacking specific interventions for ADLs. The MDS and Care Area Assessment (CAA) documented the resident's dependence on staff for toileting, transfers, dressing, and personal hygiene, as well as the need for a mechanical lift and limited time in a chair due to a wound vac. Despite these needs, the care plan did not include detailed instructions for staff on how to provide necessary assistance with toileting hygiene, transfers, bathing, oral hygiene, dressing, and eating. Staff interviews revealed that CNAs relied on verbal reports from previous shifts or nurses to determine the care needs of residents, rather than written care plan instructions. Administrative nursing staff acknowledged that the care plans should have included detailed directions for staff and that the omission was an error. The facility's own policy required comprehensive, individualized care plans to guide staff in providing person-centered care, but this was not followed for the two residents identified in the sample.