Failure to Update Care Plans for Activities and Infection Control
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect resident-centered activity preferences and infection control measures for sampled residents. For one resident, observations and interviews revealed that although she participated in some activities, such as church services and family visits, her care plan did not document her specific preferences, the importance of church, or her limited participation in group activities. Staff interviews confirmed that changes in activity participation were not consistently documented in the care plan, and the care plan lacked individualized interventions such as one-to-one visits. Another resident, who was hard of hearing and rarely participated in group activities, also had a care plan that did not reflect her interests or preferences. Despite being dependent on staff for social needs and having recently moved cottages, her activity assessment was incomplete, and care team meeting notes were left blank regarding activities. The care plan failed to include her enjoyment of family visits and music or the use of one-to-one visits to address her needs. Additionally, a resident with an indwelling urinary catheter had enhanced barrier precaution signage on her door, but there was no personal protective equipment available for staff, and her care plan did not include interventions for enhanced barrier precautions. Staff interviews indicated that care plans were not updated to include these precautions, despite facility policy requiring such updates for residents with indwelling medical devices. The care plan only addressed the presence of the catheter and related self-care deficits, omitting necessary infection control interventions.