SANTA ANA, CA - Federal inspectors found St Edna Subacute and Rehabilitation Center failed to maintain accurate care plans for multiple residents, creating dangerous confusion about life-saving medical interventions and treatment protocols.
Critical Documentation Errors Discovered
The June 21, 2024 inspection revealed the 1929 N. Fairview Street facility failed to ensure comprehensive care plans accurately reflected residents' current medical needs and treatment directives. Inspectors identified significant discrepancies in documentation for two residents that could have compromised their care.
The most serious violation involved a resident whose care plan incorrectly indicated "Do Not Resuscitate" (DNR) status when medical orders clearly showed the resident had full code status requiring cardiopulmonary resuscitation attempts. This type of error could prove fatal in an emergency situation.
Life-Saving CPR Directive Mix-Up
One resident's case highlighted the severity of improper care plan management. The resident's official medical orders from physicians clearly documented full cardiopulmonary resuscitation status, meaning staff should attempt CPR in case of cardiac or respiratory arrest. However, the resident's care plan contained contradictory information.
The care plan problem section, initiated by the Social Services Director, incorrectly stated the resident "desired no life-prolonging measures in the event of a cardiac or respiratory arrest" and included interventions for "no CPR." When questioned by inspectors, the Social Services Director acknowledged initiating the incorrect care plan but "did not know why Resident 32 was DNR when her code status was a full code."
This documentation error created a dangerous situation where nursing staff might follow the incorrect care plan instead of the physician's actual orders during a medical emergency. CPR decisions are among the most critical medical directives in healthcare facilities, as they determine whether life-saving interventions occur during cardiac or respiratory arrest.
Medical Implications of Care Plan Failures
Care plans serve as the primary communication tool between healthcare providers, ensuring all staff members understand each resident's specific medical needs, treatment goals, and intervention protocols. When these documents contain inaccurate information, the consequences can be severe.
Cardiopulmonary resuscitation status confusion poses immediate life-threatening risks. If nursing staff followed the incorrect care plan during an emergency, they might withhold potentially life-saving CPR from a resident who specifically consented to full resuscitation efforts. Conversely, attempting CPR on someone who legitimately chose DNR status violates their medical autonomy and can cause unnecessary suffering.
Professional healthcare standards require care plans to be updated within seven days of comprehensive assessments and revised whenever a resident's condition or treatment needs change. This ensures all caregivers have access to current, accurate information when making critical care decisions.
Wound Care Documentation Gaps
The inspection also revealed inadequate care plan updates for wound management. Another resident's care plan failed to reflect current wound care interventions, creating gaps in treatment documentation. Proper wound care requires detailed protocols specifying cleaning procedures, dressing changes, medication applications, and monitoring schedules.
When wound care interventions are not properly documented in care plans, nursing staff may lack clear guidance about treatment frequency, specific products to use, or signs of complications to monitor. This can lead to inconsistent care, delayed healing, or missed opportunities to prevent serious infections.
Federal Care Planning Requirements
The Centers for Medicare & Medicaid Services requires nursing homes to develop comprehensive care plans within seven days of resident admission assessments. These plans must be prepared, reviewed, and revised by interdisciplinary teams including physicians, nurses, social workers, and other healthcare professionals.
Care plans must address each resident's medical conditions, functional abilities, psychosocial needs, and personal preferences. They serve as roadmaps for individualized care, ensuring treatments align with residents' specific health goals and medical directives.
Federal regulations emphasize person-centered care, meaning treatments must reflect individual residents' preferences, values, and clinical needs. Accurate documentation ensures care teams can deliver services that respect residents' choices while meeting their medical requirements.
Consequences and Oversight
The inspection classified these violations as having "potential for minimal harm" affecting "some" residents. However, care plan inaccuracies can escalate quickly during medical emergencies when staff must make rapid treatment decisions based on available documentation.
The facility must submit a plan of correction addressing how they will ensure care plans accurately reflect residents' current medical status and treatment needs. This typically includes staff retraining, documentation review procedures, and quality assurance measures to prevent similar errors.
State and federal oversight agencies continue monitoring nursing homes to ensure compliance with care planning requirements. Facilities that fail to maintain accurate care plans may face additional sanctions, including fines or restrictions on new admissions.
For families with loved ones in nursing homes, these findings underscore the importance of regular communication with care teams and reviewing care plans to ensure they accurately reflect residents' wishes and medical needs. Residents and families have the right to request care plan updates when conditions or preferences change.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Edna Subacute and Rehabilitation Center from 2024-06-21 including all violations, facility responses, and corrective action plans.
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