Failure to Maintain Accurate and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, as identified through observation, interview, and record review. For one resident with chronic obstructive pulmonary disease and pneumonia, the care plan did not address the resident's severe hearing loss, despite documentation in the medical record and the resident's own report of difficulty hearing and lack of hearing aids. Another resident with acute kidney failure and schizophrenia had a documented DNR (do not resuscitate) order in the medical record, but the care plan incorrectly listed the resident as Full Code. Staff interviews confirmed confusion regarding responsibility for updating code status in care plans. A third resident with heart failure and acute kidney failure had a physician's order for oxygen at 2 liters per minute, but the care plan listed the oxygen setting as 3 liters per minute. Observations confirmed the resident was receiving 2 liters per minute, and staff interviews revealed a lack of communication regarding updates to care plans following order changes. For a fourth resident with seizures and cognitive deficits, the care plan listed the wrong tube feeding formula, documenting Glucerna 1.2 instead of the ordered Jevity 1.5 or equivalent. These deficiencies were identified through direct observation, resident and staff interviews, and review of medical records and care plans. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but the care plans reviewed did not consistently reflect current physician orders or the residents' assessed needs.