F0657

E

Failure to Revise and Update Resident Care Plans

Clovis, New Mexico Survey Completed on 12-05-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely revise and update comprehensive care plans for multiple residents as required. For one resident with anxiety, depression, chronic pain, constipation, paraplegia, and major depressive disorder, the physician ordered melatonin 3 mg at bedtime for insomnia, but the resident’s care plan, last revised on 12/01/25, did not include melatonin among the listed psychotropic medications (which did include mirtazapine, sertraline, buspirone, lorazepam, hydroxyzine, and tetrabenazine). Another resident with chronic pain syndrome, COPD, hypertension, depression, and atherosclerotic heart disease had a physician’s order for Voltaren gel discontinued on 09/19/25, yet the care plan revised on 11/25/25 still contained an intervention to apply Voltaren gel as ordered, reflecting outdated information.

A third resident with a history of falling, lack of coordination, cirrhosis, muscle weakness, and periorbital cellulitis had a quarterly MDS showing severe cognitive impairment and a history of falls since admission. The care plan, initiated on 02/14/25 and revised for multiple fall dates (09/18/25, 10/5/25, 10/10/25, 10/21/25, 11/1/25, 11/6/25, 11/18/25), identified the resident as at risk for falls but did not include revised interventions to ensure safety after these fall events. Another resident with a stable lumbar burst fracture, DM2, depression, and parkinsonism had a care plan revised on 04/15/25 that simultaneously documented the resident as a long-term resident with no plans for discharge and also stated a goal to increase ADL status and return home with family, indicating that discharge goals in the care plan were not updated to reflect current status.

For a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, the most recent bed rail assessment recommended quarter-size rails on both upper sides of the bed, and observation on 12/02/25 confirmed quarter-size rails in place. However, the physician order dated 09/23/24 specified half-size bed rails, and the care plan revised on 11/19/25 documented use of half-size rails, showing the care plan did not reflect the current quarter-size rails in use. Another resident with severe protein-calorie malnutrition, acute and chronic respiratory failure with hypoxia, cachexia, and chronic diastolic heart failure had a physician’s order for a wander guard discontinued on 10/07/25, but the care plan revised on 11/12/25 still listed an intervention for a wander guard in place. In an interview, the DON confirmed that the care plans for these residents were not revised to include or remove the respective medications, devices, fall interventions, discharge goals, and bed rail sizes as appropriate.