Failure to Update and Revise Care Plans Following Changes in Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were updated and revised for five residents following changes in their care needs or interventions. For one resident with multiple diagnoses including multiple sclerosis and muscle weakness, a trapeze bar was observed in use for mobility and repositioning, but this intervention was not reflected in the care plan. The Director of Nursing confirmed that the care plan had not been revised to include this equipment. Two residents receiving or previously receiving hospice care did not have their care plans updated accordingly. One resident's care plan contained outdated hospice interventions from over a year prior, despite the resident no longer being on hospice. Another resident, currently on hospice as indicated by the Minimum Data Set, had no mention of hospice care in the comprehensive care plan. The Assistant Director of Nursing confirmed these omissions and stated that care plans should be revised to reflect hospice status when relevant. Additional deficiencies included a resident with a cognitive communication deficit whose care plan listed the use of a communication board with word cards, although this intervention was no longer in use and not available in the resident's room. Staff interviews confirmed the communication board was ineffective and had been discontinued, but the care plan was not updated. Another resident with a DNR advance directive had this order documented in the medical record and on the MOST form, but the care plan did not reflect the DNR status. The Director of Nursing confirmed the care plan was not revised after the DNR order was established.