Failure to Update Care Plan for Comfort Care Status
Penalty
Summary
The facility failed to revise the care plan for a resident who had recently changed her code status to DNR with comfort care only. Despite clear documentation from the medical provider and dietician, as well as the resident's updated POLST and expressed wishes for comfort care, the care plan dated several weeks after these changes did not include any focus area, goals, or interventions specific to comfort care. Staff interviews confirmed that the resident had declined hospitalization and invasive treatments, opting instead for comfort care, and that the care plan updates were the responsibility of a specific staff member following daily meetings. Medical records showed the resident had been diagnosed with Influenza A and pneumonia, was experiencing poor appetite and low energy, and had made a clear decision, with family present, to receive only comfort care. However, the care plan was not updated to reflect these significant changes in the resident's condition and care preferences, as required by facility policy and regulatory standards.