Failure to Timely Update and Accurately Reflect Resident Needs in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulation. For two residents with dementia and cognitive impairment, an incident involving inappropriate sexual interaction was not documented in their care plans in a timely manner. The incident occurred between a male and a female resident, both of whom had moderate to severe cognitive deficits and required significant assistance with activities of daily living. Despite the incident being reported and discussed among staff and with responsible parties, the care plans for both residents were not updated to reflect the event or to include specific interventions until more than a month later. Additionally, the facility did not ensure that the care plan for a third resident accurately reflected her behavioral symptoms. This resident, who had severe cognitive impairment and was bedbound, exhibited behaviors such as yelling without stimulus and fighting the air. However, these behaviors were not consistently documented in her medical record or reflected in her MDS assessment. Interviews with staff revealed a lack of communication and documentation regarding the resident's behaviors, leading to an incomplete and potentially inaccurate care plan. The facility's own policy requires an interdisciplinary approach to care planning, ongoing assessment, and timely updates to care plans when residents' conditions change or after significant events such as hospital readmissions. Despite this, the care plans for the affected residents were not promptly or accurately updated following behavioral incidents or changes in condition, as confirmed by staff interviews and record reviews.