Failure to Update and Revise Care Plans for Resident Needs
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of two residents. For one resident with dementia and dysphagia, the care plan did not include specific dietary needs as indicated by physician orders and a nutritional assessment, such as the requirement for moderately thick liquids, thin water between meals, small bites of food, and specific swallowing techniques. Despite these needs being documented in other records, the care plan was not updated to reflect them. For another resident with Parkinsonism syndrome and chronic pain, the care plan documented a history of post-traumatic stress syndrome due to past abuse but was not revised to include a new allegation of sexual abuse by a staff member. The incident was documented in an incident report, but the care plan was not updated to address this significant event. These omissions were confirmed by facility staff during interviews.