Failure to Revise and Document Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs of two residents. For one resident with diagnoses including Parkinsonism, a rare brain disease, and dementia, the care plan identified the resident as an elopement risk but was not updated after multiple incidents of elopement. The resident was involved in two separate elopement events: in the first, the resident exited through a gate in the smoking area and was found in the parking lot, and in the second, the resident was found by police approximately 1.7 miles away from the facility after being reported missing. Despite these incidents, the only direct intervention implemented was one-on-one supervision, and the care plan was not revised to include new interventions addressing the repeated elopement attempts. For another resident with cognitive intactness and physical impairments, there was no documentation of any care plan meeting being completed from admission through over a year later. Although the social worker reported that care conferences were scheduled and completed on two occasions, there was no documentation available to confirm these meetings. The lack of documented care plan meetings indicates that the resident's care plan was not reviewed or revised as required, failing to ensure that the care plan reflected the resident's current needs.