Failure to Update and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that care plans (CPs) were updated and revised periodically and as needed for several residents, as required by both facility policy and regulatory standards. For one resident who used hearing aids, repeated observations showed the resident was not wearing them, and staff confirmed the care plan did not reflect the resident's current preference not to use hearing aids. Another resident with a mental health diagnosis and an order for antipsychotic medication did not have a care plan addressing the mental health diagnosis itself, only the medication. Staff acknowledged this omission during review. A third resident with a history of kidney and heart failure, who had transitioned from tube feeding to eating soft food without difficulty, still had a care plan indicating dependence on tube feeding, which staff confirmed was outdated. Additionally, a resident dependent on staff for all activities of daily living (ADLs) had a care plan that did not specify the correct bathing schedule or include physical therapy recommendations for daily wheelchair use and positioning, despite these being part of the resident's current care needs. These findings were based on direct observation, interviews with staff, and review of medical records and care plans.