Failure to Update Care Plans and Complete Required Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner following changes in residents' conditions and did not consistently complete or document required care conferences. For one resident with diabetes, mood disturbance, dementia, and a pressure ulcer, the care plan was not updated to reflect the development of a stage III pressure ulcer, despite a physician's order for treatment and confirmation by nursing staff. The facility's policy required care plans to be revised as needed, but this was not followed. Multiple residents did not have evidence of care conferences being held or documented as required. One resident with congestive heart failure, diabetes, COPD, depression, and schizoaffective disorder had no documented care conferences, and the care plan was not updated to include a new diagnosis of schizoaffective disorder. Another resident with a fracture, PTSD, depression, and glaucoma had no care conference documented for over a year. Additional residents with various diagnoses, including cognitive impairment and physical disabilities, either had no care conferences documented or had incomplete documentation, such as missing signatures or dates. Interviews with residents and clinical staff confirmed the lack of care conferences and incomplete or outdated care plans. Facility policy required care plan discussions with residents and/or their representatives at regular intervals and after significant changes, with proper documentation and signatures, but these procedures were not consistently followed for several residents reviewed.