Failure to Revise Care Plans for Code Status, Pressure Ulcer, and Bed Rail Discontinuation
Penalty
Summary
The facility failed to ensure that comprehensive care plans were accurately revised and updated for three residents, as required. For one resident with end stage renal disease on hemodialysis, the care plan incorrectly listed the code status as Do Not Resuscitate (DNR), despite both the physician's order and the advance directive indicating the resident was a full code. Multiple staff interviews revealed confusion regarding responsibility for updating the code status in the care plan, with MDS Nurses, the Social Worker, and the Administrator each providing differing accounts of who should make these updates. Another resident, who was readmitted with a stage 4 pressure ulcer of the sacrum, had a care plan that failed to include a newly developed stage 3 pressure ulcer on the right buttocks, despite a physician's order for wound care to that area. Staff interviews confirmed that the new wound should have been added to the care plan, and that MDS Nurses were responsible for making this update after being informed of new wounds during morning meetings. However, the stage 3 pressure ulcer was not incorporated into the care plan. A third resident, admitted with a history of stroke, had a care plan that continued to reference the use of bed rails even after the rails had been removed due to changes in the resident's cognition and safety needs. Observations and staff interviews confirmed that bed rails were no longer present or in use, and that the decision to remove them had been communicated in a morning meeting attended by the interdisciplinary team, including MDS Nurses. Despite this, the care plan was not updated to reflect the discontinuation of bed rails.