Failure to Timely Update Care Plan and Kardex After Assessment
Penalty
Summary
The facility failed to review and revise the care plan for a resident after a comprehensive assessment, as required. Specifically, the Kardex for a female resident with severe cognitive impairment, anxiety disorder, communication deficit, and dementia was not updated in a timely manner to reflect her need for extensive assistance with two staff members for transfers via mechanical lift. The quarterly MDS assessment indicated this level of assistance was necessary, but the Kardex continued to list her as requiring assistance from only one staff member during transfers. Interviews with facility staff revealed that the MDS nurse did not update the Kardex until several weeks after the assessment, acknowledging that this oversight could prevent staff from being aware of the resident's correct transfer status. The DON confirmed that the update should have occurred immediately after the assessment and that failure to do so could negatively affect residents. Facility policy requires care plans to be reviewed and revised after each assessment, but this was not followed in this instance.