Failure to Maintain Accurate and Updated Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were accurate and up to date, as required. For one resident, the care plan listed a do not resuscitate (DNR) code status, while the most current New Mexico Orders for Scope and Treatment (MOST) form indicated an attempt resuscitation code status. This discrepancy was not corrected after the resident returned from the hospital, as confirmed by the Director of Nursing (DON) during an interview. The resident's medical history included spinal stenosis, type 2 diabetes mellitus with hyperglycemia, depression, and chronic diastolic heart failure. The resident was also assessed as cognitively intact. For the second resident, the care plan did not reflect updated preferences for bathing frequency, as the Bathing Preference Sheet was changed to once a week, but the care plan still indicated a choice between bed baths or showers twice per week. Additionally, the care plan listed a DNR code status, while the MOST form indicated an attempt resuscitation code status. The DON confirmed that the care plan should have been revised to match the most current MOST form and to include a care plan for refusals of care, but these updates were not made.