Failure to Update and Revise Care Plans to Reflect Resident's Current Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the current care needs of a resident. Specifically, a resident admitted with perineal and sacral wounds, urinary incontinence, and cognitive impairment had discrepancies in their care documentation. The Quarterly Minimum Data Set (MDS) assessment indicated the resident was continent of bowel and bladder and did not have an indwelling urinary catheter. However, the resident's care plan for an indwelling urinary catheter, last revised months after the catheter was removed, still directed staff to perform catheter care every shift. Nursing assistant documentation for the last 30 days showed the resident was incontinent of bladder with no mention of a catheter, and direct observation confirmed the absence of a catheter. Interviews with staff revealed that the care plan had not been updated to reflect the resident's current status. The MDS Coordinator acknowledged that the care plan should have been updated, and the Social Service Director confirmed that the discharge care plan did not reflect the resident's current discharge goal. These failures resulted in care plans that did not accurately represent the resident's needs or status, as evidenced by outdated interventions and goals.