Failure to Update and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to care planning and communication of critical care needs. For one resident with severe cognitive impairment and dysphagia, the care plan did not address the physician's order for nectar thickened liquids, despite documentation in the medical record and staff interviews confirming the need for this intervention. Staff interviews revealed that the omission of thickened liquids from the care plan could result in staff not being aware of the dietary requirement, increasing the risk of inappropriate food or liquid consistency being provided. In the case of another resident with a planned weight loss, the facility did not update the care plan to reflect the physician's and dietitian's recommendations for a multivitamin with minerals and supplemental protein drinks. Although the resident experienced significant weight loss over a short period, the care plan did not include the new interventions, and there was a delay in entering the orders into the electronic medical record. Interviews with nursing staff and administration indicated confusion regarding the process for updating care plans and implementing recommendations, with some staff considering dietitian recommendations as optional until reviewed by a physician. The report documents that the facility's interdisciplinary team did not consistently update care plans to reflect changes in residents' needs or physician orders. Staff interviews confirmed that care plans were not always revised in a timely manner, and there was a lack of clarity regarding responsibility for updating care plans and entering orders. The RAI Manual and federal regulations require that care plans include measurable objectives and timeframes to address all identified needs, but this was not consistently done for the residents reviewed.