Failure to Update Care Plan with Resident Preferences and Therapy Recommendations
Penalty
Summary
The facility failed to revise and update the care plan for a resident who was cognitively intact and required assistance with activities of daily living (ADLs) such as dressing, grooming, bathing, mobility, and incontinence care. The resident had multiple medical diagnoses, including multiple sclerosis, malnutrition, thrombocytosis, and pseudobulbar affect, and had recently undergone a laparoscopic hysterectomy with four surgical sites. The comprehensive assessment identified the resident's preferences for bathing and clothing choices, but the care plan did not specify these preferences or provide detailed instructions for staff regarding transfers, wheelchair positioning, or the amount of time the resident should spend in a wheelchair. Despite therapy recommendations for the use of an EZ stand for transfers and for the resident to be up in a chair three times daily, these interventions were not reflected in the care plan or the nursing assistant care sheet. The care sheet also lacked information on interventions to facilitate easier transfers and mobility, particularly in relation to the resident's spastic rigidity caused by multiple sclerosis. Staff interviews revealed uncertainty about how to manage the resident's care needs, including safe transfers and addressing her rigidity, and the resident reported that staff did not allow her sufficient time to relax during transfers, which exacerbated her rigidity. Additionally, the care plan and care sheet were not updated to reflect the resident's expressed preferences for bathing and hair washing, even after these concerns were raised during a care conference. The director of nursing confirmed that care plans should be updated to reflect resident preferences and therapy recommendations, and that changes made to care sheets should be mirrored in the care plan. However, the documentation reviewed did not show that these updates were made, resulting in a lack of clear direction for staff on how to provide care according to the resident's needs and preferences.