Failure to Review, Revise, and Implement Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and implemented for two residents. For one resident with muscular dystrophy and dysphagia, the care plan did not include a newly ordered intervention of a floor mat after a fall, and the mat was observed not to be in place at the bedside as required. Additionally, this resident's nutrition care plan required supervised dining in specific areas, but she was repeatedly observed eating unsupervised in her bed, contrary to the documented interventions. For another resident with traumatic brain dysfunction and significant cognitive impairment, the care plan addressing communication difficulties had not been updated with new interventions since 2020. The care plan called for the use of a communication board and monitoring of frustration levels, but no communication board was found in the resident's room, and there was no documentation of monitoring in the medical record. Staff reported ongoing difficulty understanding the resident, and the resident indicated he did not have or know about a communication board.