Failure to Update Care Plan Following Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to update the care plan for a resident experiencing a significant decline in condition. The resident, who had diagnoses including terminal lung cancer, malnutrition, asthma, and chronic lung disease, was previously independent with activities of daily living (ADLs) such as bathing, toileting, and dressing, as documented in her care plan and bedside Kardex. However, observations over several days showed the resident was increasingly dependent, remaining in bed, unresponsive to verbal stimulation, and wearing the same clothing for multiple days. Staff interviews confirmed that the resident now required assistance with all personal cares, including bathing, toileting, and dressing, due to her declining condition. Despite these changes, the care plan and Kardex were not updated to reflect the resident's increased need for assistance. Nursing staff, including the registered nurse and CNA, acknowledged that the care instructions in the Kardex were outdated and did not match the resident's current needs. The nurse manager and DON both confirmed that the care plan had not been revised to address the resident's decline, even though facility policy required care plans to be reviewed and updated upon a change in status. The facility's own policy outlined a process for reviewing and revising care plans when a resident experiences a status change, including notification of the MDS coordinator, collaboration with the interdisciplinary team, and communication of updated interventions to all staff. However, this process was not followed in the case of this resident, resulting in a care plan that did not accurately reflect her current care needs.