Failure to Revise and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise and update comprehensive care plans for several residents, resulting in unmet care needs. For a resident with cerebral palsy and contractures, the care plan lacked specific interventions for range of motion exercises, use of splints, and restorative programs, despite staff acknowledging the need for such interventions. The care plan also did not reflect current therapy involvement, and staff interviews confirmed that the resident was not receiving the indicated therapies or monitoring for contractures as outlined in the care plan. Another resident with a Level II PASARR for serious mental illness did not have the recommended interventions from the PASARR evaluation included in their care plan. Staff confirmed that the care plan was generic and not personalized with the required PASARR recommendations, which should have been incorporated word for word according to facility policy. The care plan had not been updated since the PASARR evaluation, despite clear expectations for quarterly review and revision when recommendations are made. Additional deficiencies were identified for residents using opioid pain medications, self-administering medications, and receiving continuous oxygen therapy. The care plans for these residents did not include necessary details such as monitoring for adverse effects of opioids, non-pharmacological pain interventions, authorization and procedures for self-administration of medications, or documentation of oxygen use. Staff interviews consistently indicated that these omissions were contrary to facility policy and expectations for care plan updates.