Failure to Revise Care Plan for Resident's Supervision Needs
Penalty
Summary
The facility failed to update and revise the care plan for a resident who was not permitted to leave the facility independently. The resident expressed a desire to be integrated back into the community and reported frustration at not being able to exercise his rights to go outside for walks or to the store without accompaniment. The activity assessment indicated that going outside for fresh air was very important to the resident. However, the care plan only included an intervention to encourage the resident to inform staff when he wanted to go out to purchase items, without addressing the new restriction that he could not leave the facility alone. The Director of Nursing confirmed that the resident was not considered safe to leave the facility on his own due to medical issues affecting his decision-making, but also stated that the resident had not been deemed incompetent. The care plan did not reflect the requirement for staff supervision when the resident left the facility, nor did it document the restriction on independent outings. The lack of care plan revision meant that the resident's current needs and restrictions were not accurately addressed in his care documentation.