Failure to Maintain Accurate and Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected the current needs and interventions for three residents. For one resident with severe cognitive impairment and a stage 4 pressure ulcer, the care plan included an intervention for negative pressure wound therapy, but there was no physician order for this therapy, and staff confirmed the resident was not receiving it. The care plan was not updated to reflect the actual wound care being provided, and the responsible staff indicated that the care plan should not have included this intervention if it was not in use. Another resident with moderate cognitive impairment and on hemodialysis did not have care plan interventions addressing the assessment and monitoring of her condition before and after dialysis treatments. The care plan only included Enhanced Barrier Precautions for the dialysis access device but lacked documentation of ongoing communication and collaboration with the dialysis facility or monitoring for complications related to dialysis. Staff interviews confirmed that dialysis care needs were not addressed in the care plan, and this omission was not identified during interdisciplinary team (IDT) reviews. A third resident, who was dependent on staff for transfers and had a history of sleeping in a recliner, had a care plan that did not accurately reflect her current transfer status or sleeping arrangements. The care plan indicated one-person assistance for transfers, while staff and the resident confirmed that a mechanical lift with two staff was required. Additionally, the care plan listed a full code status, but physician orders and documentation indicated a DNR status. Staff interviews revealed that care plans were not updated to match the resident's current needs and wishes, and there was confusion among staff regarding responsibility for maintaining accurate care plans.