Failure to Update and Individualize Resident Care Plans After Changes in Status and Incidents
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for four residents following significant changes in their care needs and status. For two residents, the care plans continued to document the use of wanderguard devices and every 15-minute safety checks, despite the absence of current physician orders and the devices not being in use. Observations confirmed that these residents were not wearing wanderguards, and staff interviews acknowledged that the care plans were not accurate or up to date. The facility's own policy required care plans to be reviewed and revised based on changing needs and interventions, but this was not followed. Another resident's care plan was not updated to reflect the resident's preferences for activities, despite the most recent assessments indicating specific interests and needs. The care plan contained only general interventions and did not individualize activities according to the resident's stated preferences. Staff interviews confirmed that every resident should have an individualized activity care plan, and the current plan did not meet this standard. Additionally, the care plans for two residents were not reviewed or revised after incidents of resident-to-resident altercations. One resident was the victim of an assault, resulting in a skin tear and facial bruising, while another resident was the aggressor in two separate incidents. Despite documentation of these events in the clinical records and staff acknowledgment that care plans should be updated following such incidents, there was no evidence that the care plans were reviewed or revised to address the new risks or interventions needed.