Failure to Update and Implement Comprehensive Care Plans After Changes in Resident Condition
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulation. For each resident, the care plans did not include measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs as identified in their comprehensive assessments. Specifically, care plans were not updated following significant changes in condition or incidents, resulting in care plans that did not reflect the current needs or required services for the residents. One resident with vascular dementia, agitation, and a history of falls experienced multiple falls over several months. Despite documentation of these incidents in progress notes and incident reports, the resident's care plan was not updated after each fall to reflect new interventions or changes in care. Interviews with staff confirmed that interventions discussed in meetings and huddles were not consistently incorporated into the written care plan in a timely manner. Another resident with severe cognitive impairment, alcohol dependence, and a history of falls and choking incidents had multiple documented falls and a choking event. The care plan included outdated interventions, such as providing a bowl of nuts, which was not appropriate for the resident's current dietary needs. The care plan was not updated with new interventions after each incident, and staff interviews revealed a lack of awareness of the resident's current care needs. A third resident with severe cognitive impairment and exit-seeking behaviors had multiple documented elopements and attempts to leave the facility. Despite these incidents, the care plan was not updated with new approaches after each event, and staff interviews indicated uncertainty about who was responsible for updating care plans.