Failure to Timely Update and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as required by policy and regulatory standards. For one resident with an indwelling urinary catheter, the care plan was not updated in a timely manner to reflect the resident's longstanding preference for a leg bag, despite staff being aware of this preference. The care plan was only revised months after the preference was established, and interviews with nursing staff confirmed that the resident had always used a leg bag. Another resident who was readmitted with a colostomy did not have this significant change in condition reflected in the care plan until several months after readmission. Although the resident had a physician's order for ostomy care and staff were providing the necessary care, the care plan was not updated to include the colostomy until it was discovered missing by the MDS nurse. The MDS nurse acknowledged that the omission occurred at the time of readmission and was not caught during daily meetings or by other staff responsible for care plan updates. Additional deficiencies were noted for a resident with severe cognitive impairment and an indwelling urinary catheter, whose care plan was not updated to include the use of a leg bag after the resident repeatedly removed the catheter. The change to a leg bag was made to address this behavior, but the care plan was not revised until much later. Another resident with severe cognitive impairment was not care planned for activities until long after admission, despite ongoing participation in bedside activities and music therapy. Staff interviews confirmed that activities were being provided, but the care plan did not reflect this until it was eventually updated.