Failure to Maintain Accurate and Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current needs and interventions for three residents. For one resident with severe cognitive impairment and a stage 4 pressure ulcer, the care plan included negative pressure wound therapy as an intervention, despite there being no physician order or evidence that this therapy was ever provided. Staff interviews confirmed that the resident was not receiving negative pressure therapy, and the care plan was not updated to reflect the actual care being provided. Another resident, who was moderately cognitively impaired and receiving hemodialysis, had a care plan that only addressed enhanced barrier precautions for her vascular access device. The care plan did not include necessary interventions such as assessment and monitoring for complications before and after dialysis, nor did it document ongoing communication with the dialysis facility. Staff interviews revealed that the omission was not identified or corrected during interdisciplinary team (IDT) reviews, and the responsibility for updating the care plan was not clearly followed. A third resident, who was cognitively intact but dependent on staff for transfers and had a DNR order, had a care plan that did not accurately reflect her current transfer needs, sleeping arrangements, or code status. The care plan listed one-person assistance for transfers, while staff confirmed that a mechanical lift with two staff was required. Additionally, the care plan indicated a full code status, while the medical record and physician orders documented DNR status. Staff interviews indicated that these discrepancies were not addressed due to lapses in updating the care plan following changes in the resident's condition and preferences.