Failure to Develop and Revise Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and revise comprehensive care plans that accurately addressed the physical needs of four sampled residents. For one resident with chronic pain and bilateral hand and knee contractures, the care plan did not specify the current fall risk status and included interventions for conditions not present in the resident's clinical record. The care plan was not updated to reflect the resident's actual diagnoses and needs, as confirmed by the DON and MDS Coordinator during review. Another resident with a recent left femur fracture and an indwelling urinary catheter had a care plan that did not reflect current ADL and toileting needs, despite changes in condition following hospitalizations and surgical interventions. Additional residents with recent fractures and mobility limitations had care plans that lacked person-centered details, such as specific assistance requirements, frequency, and interventions tailored to their post-operative and rehabilitative needs. In each case, the care plans were not revised or completed to address the residents' current physical conditions and care requirements, as confirmed by facility staff during surveyor interviews.