Failure to Review and Revise Care Plans and Inadequate Documentation of Care Plan Meetings
Penalty
Summary
The facility failed to review and revise interdisciplinary care plans to accurately reflect interventions for residents, as evidenced by two cases. In the first case, a resident with a wound on the right thigh had been receiving daily dressing changes per physician order, but the care plan did not include specific interventions or approaches to manage the skin impairment. Additionally, the clinical record lacked a description or measurements of the wound, despite documentation by a nurse noting its presence and treatment. The Director of Nursing confirmed that the care plan was not updated to include the resident's actual skin impairment and that the clinical record did not contain a description of the affected area. In the second case, a resident's significant other reported not being invited to a care plan meeting following the resident's admission. The social worker confirmed that no care plan meeting had been scheduled and that invitations were typically sent within two weeks of admission, but there was no documentation indicating that the responsible party declined the invitation or that a meeting had occurred. The deficiency was identified when the surveyor found a lack of documentation in the medical record regarding the care plan meeting process for this resident.