Failure to Revise Care Plans and Conduct Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to revise and update comprehensive care plans and to conduct required care conferences in accordance with its policy. The facility’s policy stated that care plans should be reviewed and revised when changes occur to update the plan of care. For one resident with heart disease, difficulty walking, abnormal posture, and kyphosis, the care plan still contained an outdated direction to ambulate with therapy only after a new restorative walking program was initiated, and it continued to list use of a neck brace even though the brace had been discontinued months earlier. The resident was observed holding her head at an angle with her hand, and no neck brace was present in the room. The Staff Development Coordinator acknowledged that the ambulation direction should have been discontinued when the new restorative program started and that the care plan was not updated when the neck brace was discontinued. Another resident with cellulitis of the right limb, muscle weakness, and a need for assistance with personal care had a physician order for offloading boots to be applied to both feet at all times, but this intervention was not included in the care plan, and the resident was repeatedly observed without the boots. The DON confirmed the care plan should have been revised to include this intervention. A third resident with hemiplegia and hemiparesis following a stroke transitioned to hospice services, as documented in a progress note, but the care plan did not include hospice or comfort care interventions; the ADON confirmed the care plan should have been revised upon admission to hospice. A fourth resident with PTSD, anxiety, and depression did not have documentation of quarterly care conferences for two required quarters, and the Social Services Director stated those conferences were overlooked and not completed.
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