Failure to Update and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through interviews and record reviews. For one resident, who had multiple medical conditions including multiple rib fractures, diabetes, and polyneuropathy, the care plan did not reflect a recent fall that occurred in the bathroom or the requirement for a cervical collar as ordered by the hospital. The care plan also lacked documentation of interventions such as non-slip strips and the use of the cervical collar, despite observations confirming the resident was wearing the collar. The MDS Coordinator, responsible for updating care plans, acknowledged the omission and was unable to explain how the updates were missed, despite daily meetings intended to review such changes. For another resident with diagnoses including dysphagia, dementia, and GERD, the care plan was not updated to reflect a physician's order for nectar thickened liquids. The resident's care plan continued to list a thin liquid consistency, contrary to the updated order for nectar thick liquids. Staff interviews confirmed that the care plan should have been updated to reflect the new dietary requirement, but this was not done. The DON and Administrator both stated that the MDS Coordinator was responsible for ensuring care plans were current and accurate, and that changes in resident needs were discussed in regular meetings. The facility's own policy requires that care plans be comprehensive, person-centered, and revised as resident conditions change, with measurable objectives and timetables. However, in both cases, the care plans were not updated to reflect significant changes in the residents' needs, as identified in assessments and physician orders. This failure was confirmed by staff and management interviews, as well as review of facility documentation.