Failure to Update ADL Care Plan After Therapy Discharge
Penalty
Summary
The facility failed to revise the Activities of Daily Living (ADL) care plan to reflect a resident's current condition following discharge from therapy. The resident, who has diagnoses including Parkinson's disease, difficulty in walking, and other comorbidities, reported feeling weaker and losing endurance since therapy ended, stating that no staff were available to supervise her walking except during family visits. Therapy had instructed the resident to ensure supervision while walking, but this was not consistently provided after discharge from therapy. Interviews with staff revealed that Certified Nursing Assistants (CNAs) did not have time to assist with walking or range of motion exercises, and these tasks were typically assigned to a restorative aide. However, the restorative aide position had not been filled, and the restorative program was not operational, leaving no one to oversee or provide the necessary support. The Director of Rehabilitative Services confirmed that although the resident was discharged from therapy with a home exercise program, the facility lacked a restorative program and staff to implement it. A review of the resident's care plan showed it had not been updated to address the resident's current needs or the lack of restorative services. The care plan continued to list general approaches such as providing assistive devices and encouraging independence, but did not reflect the resident's need for supervised walking or the absence of restorative support. Facility policy requires care plans to be updated with any change in condition, but this was not done in this case.