Failure to Revise Care Plans with Current Resident Information and Interventions
Penalty
Summary
The facility failed to ensure that care plans were revised to reflect the most current information and interventions for three residents. For one resident, staff observed a strong odor of urine and noted the resident was only wearing a soiled brief with no sheets on the bed. Interviews with the ADON and DON revealed that the resident frequently refused care, including changing briefs, showering, and having sheets on the bed, and that staff sometimes used Diet Dr. Pepper and chips as incentives for compliance. However, the care plan did not document these interventions, nor did it include strategies for managing refusals of care, changing sheets, or the frequency of mattress changes. The DON confirmed that the care plan had not been updated to reflect these interventions or the resident's current care needs. Another resident experienced a fall due to weakness and imbalance and was subsequently enrolled in a restorative program to address these issues. Despite this, the care plan was not updated to include participation in the restorative program as an intervention to prevent further falls. For a third resident, physician orders indicated a change from a regular diet to enteral feeding via G-tube, along with specific medication administration instructions. The care plan, however, lacked details on whether male staff could provide feeding or medication administration and did not specify how to ensure the resident received nutrition and medications as ordered. The DON confirmed these omissions in the care plan documentation.