Failure to Update Care Plan with Resident's Caregiver Preference
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plan for one of six residents in the survey sample. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, dysphagia, anemia, protein-calorie malnutrition, asthma, cognitive communication deficit, hypothyroidism, myocardial infarction, and hypertension, and was assessed as having severely impaired cognitive skills. A nursing note documented that a family member requested the resident not have male caregivers if possible. However, the care plan, last revised on 7/21/25, did not include this preference. During an interview, the RN MDS coordinator confirmed that the preference was not documented in the care plan, although staff were aware of it. No additional information was provided by the facility prior to the end of the survey.