F0657

D

Failure to Update and Align Care Plans With Current Orders and Resident Preferences

York, Pennsylvania Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to review and revise person-centered care plans to reflect current assessments, physician orders, and resident preferences for three residents. For one resident with diabetes mellitus, protein calorie malnutrition, multiple sclerosis, and end-stage kidney disease, smoking assessments documented that independent smoking was allowed off site on one date, and later that the resident was not allowed to smoke. Physician orders also addressed leave of absence (LOA) privileges, including independent LOA with medications, LOA with a responsible party, and permission to go to the end of the drive independently, with various start, hold, and discontinuation dates. However, the resident’s care plan contained conflicting entries stating both that the resident may not smoke per smoking evaluation and that the resident may smoke independently per smoking evaluation, and it was not updated to reflect the current smoking and LOA status.

For another resident with hypertension and end-stage renal disease, physician orders documented a full code status, but the interdisciplinary plan of care listed the resident’s code status as DNR, creating a discrepancy between the care plan and the physician’s orders. A third resident with diabetes and GERD had multiple progress notes documenting discussions about discharge options, including the daughter’s desire for discharge home after renovations, the resident’s resistance to leaving because she felt safe at the facility, and later her agreement to a possible discharge to an independent living facility. Despite these documented discussions and changing preferences, the resident’s care plan did not include her choice for discharge or long-term care placement, which the NHA acknowledged should have been reflected to avoid confusion.