Failure to Update Care Plans with Discharge Preferences and Advanced Directives
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all resident needs, specifically omitting documentation of services provided due to residents' exercise of rights, residents' preferences, and potential for future discharge. For five out of seven residents reviewed, care plans did not include information regarding the residents' preferences for discharge or whether their desire to return to the community had been assessed. Additionally, the care plan for one resident was not updated to reflect an advanced medical directive, despite a current and verified Do-Not-Resuscitate (DNR) order being present in the medical record. Record reviews revealed that residents with significant cognitive impairments and complex medical histories, including severe anxiety, dementia, depression, heart failure, and respiratory failure, did not have discharge planning documented in their care plans. In one case, a resident with a DNR order had conflicting documentation in the care plan, which still listed a Full Code CPR order. Interviews with facility staff, including the RN, DON, MDS Coordinator, and Administrator, indicated a lack of clarity regarding responsibility for updating care plans, particularly for DNR status and discharge planning. Staff interviews further revealed that the social worker (SW) was generally expected to update care plans with DNR status and discharge planning, but there was confusion and lack of awareness among the interdisciplinary team about these responsibilities. The absence of discharge planning and updated advanced directives in the care plans was not recognized by the staff until brought to their attention during the survey, and the SW responsible for these updates was unavailable for interview at the time.