Care Plan Not Updated to Reflect Resident's Routine Preferences
Penalty
Summary
The facility failed to update a resident's comprehensive care plan to reflect the individual's stated preferences for morning and evening routines. The resident, who had diagnoses including heart failure, previous stroke with right side paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, was assessed as having intact cognition but required total staff assistance for activities of daily living such as toileting, dressing, hygiene, bed mobility, and transfers. The resident was also frequently incontinent of bowel and had an indwelling urinary catheter. During a care plan conference attended by the resident and spouse, the preference for being up and out of bed at 7:00 AM and going to bed at 8:30 PM was clearly communicated. However, a review of the care plan, last revised after this conference, showed no documentation of these preferences. The care plan only included interventions related to positioning and transfer assistance, without addressing the resident's specific requests for daily routine times. The DON confirmed in an interview that the care plan had not been updated to include these preferences.