Failure to Review and Revise Care Plans After Assessments and Changes in Condition
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment or change in condition for four out of five sampled residents. For one resident with severe cognitive impairment and a history of falls, the care plan had not been updated following multiple falls and hospitalizations, despite documentation of these events in progress notes. Observations also revealed the resident continued to attempt to get out of bed, and interventions such as an extra mattress were implemented without corresponding updates to the care plan. Another resident was admitted with multiple complex diagnoses, but a comprehensive care plan was not developed following admission, nor was a baseline care plan completed within the required timeframe. The MDS Coordinator confirmed that the care plan was overdue and not available for staff reference. Additionally, a resident who was started on hospice services did not have this significant change reflected in their care plan, as the last revision predated the hospice order. A further resident experienced multiple falls over several months, with some falls lacking documented interventions and others having interventions that were not incorporated into the care plan. The care plan did not reflect the resident's recent falls or the interventions implemented, and a significant change MDS assessment was not completed within the required timeframe. The facility's policy required care plans to be reviewed and revised after comprehensive assessments and significant changes, but this was not consistently followed for the sampled residents.