Failure to Update and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulatory standards. For one resident with a diagnosis of dementia and Alzheimer's disease, the most recent care plan did not include dementia as an active diagnosis, despite the resident's medical record and MDS assessment indicating its presence. Interviews with facility staff revealed that the care plan was not updated to reflect this diagnosis, with staff citing a lack of recent physician documentation and a high BIMS score as reasons for omission. The MDS nurse acknowledged that dementia was included on the MDS due to hospital discharge information but was not care planned because it was not considered an active diagnosis by the physician at the time. Another resident, who was being treated for pneumonia with antibiotics, did not have this treatment reflected in their care plan. The care plan, dated prior to the pneumonia diagnosis and antibiotic order, was not updated to include the new medical intervention. Staff interviews confirmed that the care plan should have been updated immediately upon receipt of the antibiotic order, and failure to do so could impact the delivery of necessary care. The facility's policy requires that care plans be updated promptly to reflect new diagnoses and treatments, but this was not followed in this instance. Record reviews and staff interviews consistently indicated that the lack of timely updates to care plans could result in gaps in communication and care delivery. The facility's own policy mandates the inclusion of measurable objectives and timeframes in care plans to address all identified needs, but these requirements were not met for the two residents in question. The findings demonstrate that the facility did not ensure care plans were current and comprehensive, as required by both internal policy and federal regulations.