Failure to Update and Maintain Accurate Resident Care Plans
Penalty
Summary
Surveyors found that the facility failed to ensure care plans were updated to reflect the current care needs of two residents. For one resident, observations and interviews revealed inconsistencies between her actual care needs and what was documented in her care plan. She was observed primarily using a wheelchair and requiring staff assistance for ambulation and toileting, yet her care plan indicated she was independent with these activities and used incontinence products inconsistently with her current needs. Staff interviews confirmed that care sheets and care plans contained conflicting information regarding her mobility and incontinence care. For another resident, the care plan was not updated after his urinary catheter was discontinued, despite medical records and staff interviews confirming he no longer had a catheter. The DON acknowledged that care plans were not being audited for accuracy and that staff, including some nurses, were not updating care plans as required. Additionally, one LPN reported not knowing how to update care plans. The facility's policy required licensed professionals to update care plans, but this was not consistently followed.