Failure to Revise Care Plans for Individual Resident Needs
Penalty
Summary
The facility failed to revise and update comprehensive care plans to address the individual care needs of two residents. For one resident, the care plan included interventions for fragile skin that required monitoring the effectiveness of zinc oxide cream treatment. However, medical record reviews and staff interviews revealed that the effectiveness of the treatment was not being evaluated or documented, despite the care plan's directive. Staff, including LVNs and the DON, confirmed that maintenance treatments were not evaluated for effectiveness, and the care plan intervention to monitor effectiveness was not being followed or considered necessary. For another resident, the care plan included an intervention to encourage verbalization of feelings, despite documentation and staff interviews indicating the resident had no capacity to understand or make decisions and was rarely or never understood. The resident was unable to verbalize needs, and staff acknowledged that the intervention was not realistic or appropriate for the resident's current cognitive status. The care plan had not been updated to reflect these changes, and the intervention remained inaccurate.