Failure to Complete and Update Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were completed and updated to address all aspects of care for three residents. For one resident with Stage 3 and Stage 4 pressure injuries and an indwelling urinary catheter, the care plan did not document the indication or justification for catheter use, despite the need to prevent contamination of pressure ulcers. Staff acknowledged that the care plan should have specified the catheter's purpose but did not. Another resident with therapeutic nutritional risk had a care plan that was not updated to reflect their history of refusal, need for encouragement with food and fluid intake, and other relevant interventions, as confirmed by the dietician and resident care manager. A third resident with a diagnosis of anemia and recent hospitalization for blood transfusions did not have a specific care plan addressing anemia, monitoring considerations, or transfusion history. Additionally, the care plan for this resident's visual impairment did not mention their use of corrective lenses or related needs, despite the resident reporting difficulty reading and requiring staff assistance. Staff interviews confirmed that these omissions were not in line with facility expectations for care plan updates following changes in condition or hospitalizations.