Failure to Update Care Plans for Code Status and Bedrail Use
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for several residents to accurately reflect their current code status and the use of bedrails. For one resident with dementia, although a physician's order for Do Not Resuscitate (DNR) was obtained and all necessary paperwork was completed, the care plan continued to indicate a desire for Cardio-Pulmonary Resuscitation (CPR) and full code status. The MDS Nurse, who was responsible for updating the care plan, acknowledged that the care plan should have been revised immediately after the DNR order was finalized but admitted to missing this update. Both the Director of Nursing and the Administrator confirmed that the care plan should have reflected the resident's DNR status. For two other residents with chronic medical conditions, including hypertensive heart disease, chronic kidney disease, and heart failure, the facility failed to include the use of bilateral u-shaped grab bars (bedrails) in their comprehensive care plans. Assessments documented the use of these assistive devices, and both residents confirmed their ongoing use for mobility and positioning in bed. Despite this, the care plans did not reference the bedrails, and observations confirmed their presence and use during the survey. Interviews with the MDS Nurse, Administrator, and DON revealed a lack of awareness that the use of u-shaped grab bars needed to be included in the residents' care plans. All three staff members stated they were unaware of this requirement, despite being responsible for creating and updating care plans. This oversight resulted in care plans that did not accurately reflect the residents' current needs and interventions.