Failure to Review and Update Care Plans After Quarterly Assessment
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly Minimum Data Set (MDS) assessments. Specifically, the care plans addressing medication refusals, physical aggression, social needs, and nutritional problems for a resident with diagnoses such as vascular dementia, cardiomyopathy, and mood disorder were not reviewed or updated in conjunction with the quarterly MDS completed on 12/17/2024. The care plans had last been revised on various dates prior to the quarterly assessment, and there was no documentation indicating that the interdisciplinary team had reviewed or updated them at the required interval. Interviews with facility staff, including the MDS Coordinator RN and the Assistant Administrator, confirmed that the process for care plan review and updates was not consistently followed. The MDS Coordinator RN acknowledged that while care plans are supposed to be reviewed quarterly and updated as changes occur, there was no notation or documentation in the care plans to indicate that a review had taken place if no changes were needed. The Assistant Administrator stated that responsibility for updating care plans is shared among the nursing supervisor, MDS coordinator, and other team members, but the required quarterly review and documentation were not evident in the resident's records.