Failure to Revise Care Plans for Resident Safety and Activity Preferences
Penalty
Summary
The facility failed to revise and update comprehensive care plans for two residents as required. For one resident, repeated refusals to wear a safety apron while smoking were observed and documented by staff, but this behavior was not reflected in the resident's care plan. Staff interviews confirmed that the refusal was ongoing and known to the care team, yet the care plan was not updated to address this behavior, despite expectations from nursing leadership that it should have been included. For another resident, the quarterly Minimum Data Set (MDS) assessment identified specific activity preferences, including being around animals, doing favorite activities, and going outside for fresh air. These preferences were marked as very important by the resident's representative. However, a review of the resident's activity care plan showed that these preferences were not incorporated. Staff involved in care planning acknowledged that the care plan did not reflect the resident's identified interests, and facility leadership confirmed that such preferences should be included.