Failure to Revise and Update Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs and conditions of several residents, as required by policy and regulation. For one resident with Alzheimer's disease and behavioral disturbances, the care plan did not address the resident's refusal of assistance with personal hygiene, such as nail trimming and shaving, despite staff observations and interviews indicating the resident was not independent and required reminders and cues. Staff reported repeated attempts to assist, which were refused, but this behavior and the need for partial assistance were not documented in the care plan. Another resident with a neurostimulator implant and recent back surgery required extensive assistance with toileting and had ongoing issues with bowel regulation. The resident expressed concerns about bowel management and was noted to refuse toileting and incontinence care, with staff making specific agreements to provide care. However, the care plan lacked any mention of these toileting needs or the interventions being provided. Similarly, a resident receiving hospice care had a discontinued medication (anastrozole) that remained listed in the care plan, even after the medication was stopped and hospice services began. Additional deficiencies included a resident with a feeding tube whose care plan was not updated after a significant change in diet order, allowing oral intake for quality of life, and a resident with a history of falls whose care plan was not revised to reflect frequent falls and new interventions. In each case, staff interviews confirmed that care plans were not updated in a timely manner to reflect changes in resident status, behaviors, or interventions, despite facility policy requiring such updates with each assessment or change in condition.