Failure to Update Care Plan After Significant Change in Resident Status
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident after significant changes in the resident's condition and care needs. The resident, who had a history of anoxic brain injury and was previously receiving hospice services, revoked hospice care, had a gastrostomy tube (G-tube) removed, and no longer required enhanced barrier precautions (EBP). Despite these changes, the care plan continued to reflect outdated interventions, such as coordination with hospice staff, G-tube care, and EBP related to the feeding tube. The care plan was not revised to reflect the resident's current status, including the absence of tube feedings and the discontinuation of hospice services. Interviews with facility staff confirmed that the care plan was not updated following the resident's revocation of hospice services and removal of the G-tube. Observations showed the resident was alert, able to communicate, and independently feeding himself a regular meal without swallowing issues. The failure to revise the care plan after these significant changes was confirmed by both the Director of Nursing and the MDS Director, indicating a lapse in the facility's process for timely care plan updates.