Failure to Maintain Comprehensive and Accurate Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were accurately created and maintained for two residents. For one resident with a history of stroke and hemiplegia, the care plan did not address the use of a seatbelt on the resident's wheelchair, despite observations showing the resident regularly used a seatbelt. Both the MDS Coordinator and the Administrator confirmed that the use of a seatbelt should have been included in the care plan, but it was omitted. For another resident with diagnoses including diabetes, paraplegia, urine retention, and high blood pressure, the care plan lacked specific goals and interventions for activities of daily living and other care needs. The resident was dependent on staff for showering, toileting, and hygiene, and required a mechanical soft diet, urinary catheter care, blood glucose monitoring, pain monitoring, and skin integrity interventions. These needs were documented in the resident's order summary and progress notes but were not reflected in the care plan. The resident also reported inconsistent care regarding turning, hygiene, and shower frequency. Interviews with facility staff, including the MDS Coordinator, DON, ADON, RN, CNA, and Administrator, revealed that staff rely on care plans and the electronic Kardex to determine the care required for each resident. Staff acknowledged that all necessary care interventions, preferences, and significant changes should be included in the care plan, but in these cases, the care plans were incomplete and did not reflect the residents' current needs or preferences.