Failure to Review, Revise, and Document Care Plans and Resident Participation
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect residents' current status and did not provide residents or their representatives with the opportunity to participate in the care planning process. Multiple residents with complex medical conditions, such as diabetes, end stage renal disease, dementia, congestive heart failure, hypertension, and mental health disorders, did not have documented evidence of care plan meetings being held or invitations extended to them or their representatives. In several cases, the last documented care plan meetings were many months prior to the survey, and staff could not provide further documentation of more recent meetings or invitations. Additionally, the facility did not update care plans to reflect changes in residents' conditions or physician orders. For example, one resident's care plan continued to list interventions for medications that had been discontinued, and another resident's care plan did not include a newly ordered renal diet. There were also instances where care plans failed to address significant care needs, such as incontinence care for residents who were always incontinent or had discontinued use of a foley catheter but were now frequently incontinent of bowel. Interviews with residents, their representatives, and facility staff confirmed that care plan meetings were not being held as expected, and documentation of these meetings, including invitations and attendance, was lacking. Facility policy required care plans to be reviewed and revised after each assessment and as needed, and for care plan meetings to be documented, but these requirements were not met for several residents during the review period.