Failure to Maintain Accurate and Updated Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to care planning and documentation. For one resident with a history of diabetes, schizoaffective disorder, and hypertension, a pressure ulcer present upon re-admission was not included in the care plan until several weeks later, despite nursing documentation and staff interviews confirming the wound's existence and the expectation that such conditions be care planned promptly. The care plan was only updated after a significant delay, even though the wound was reported to the MDS Nurse at the morning meeting following re-admission. Another resident with mobility issues and a history of elopement risk was documented in the care plan as having a wander guard in place, but observations and staff interviews confirmed that the resident did not have a wander guard at the time. The administrator confirmed that no residents currently had wander guards, indicating a discrepancy between the care plan and the resident's actual status. This inconsistency was not identified or corrected by the staff responsible for updating care plans. A third resident, diagnosed with dementia and severe cognitive impairment, was documented in the care plan as residing on a secured memory care unit due to exit-seeking behaviors. However, social services notes and direct observation showed that the resident had been moved to a regular room months earlier, and the care plan was not updated to reflect this change. Interviews with the DON and MDS Nurse revealed confusion and lack of clarity regarding responsibilities for updating care plans, contributing to the failure to maintain accurate and current care plans as required by facility policy.